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7181. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41153/psn-pdf
      January 01, 2013 - Quality improvement for patient safety: project-level versus program-level learning. December 12, 2012 Rivard PE, Parker VA, Rosen AK. Quality improvement for patient safety: project-level versus program- level learning. Health Care Manage Rev. 2013;38(1):40-50. doi:10.1097/HMR.0b013e318245019f. https://psnet.ahrq…

7182. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60805/psn-pdf
      August 12, 2020 - A blueprint for leadership during COVID-19. August 12, 2020 Rosa WE, Schlak AE, Rushton CH. A blueprint for leadership during COVID-19. Nurs Manage. 2020;51(8):28-34. doi:10.1097/01.numa.0000688940.29231.6f. https://psnet.ahrq.gov/issue/blueprint-leadership-during-covid-19 These authors discuss the effect of the C…

7183. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34638/psn-pdf
      December 23, 2008 - What is accountability in health care? December 23, 2008 Emanuel EJ, Emanuel LL. What is accountability in health care? Ann Intern Med. 1996;124(2):229-239. https://psnet.ahrq.gov/issue/what-accountability-health-care This perspective details the concepts surrounding “accountability” in health care. The discussion …

7184. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34708/psn-pdf
      February 18, 2011 - Understanding and responding to adverse events. February 18, 2011 Vincent CA. Understanding and Responding to Adverse Events. New Engl J Med. 2003;348(11):1051- 1056. doi:10.1056/nejmhpr020760. https://psnet.ahrq.gov/issue/understanding-and-responding-adverse-events In this article, Vincent describes the investiga…

7185. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47954/psn-pdf
      August 07, 2019 - Special Issue on Resilience Engineering and High Reliability Organizations. August 7, 2019 Wears RL, Roberts KH, eds. Safety Sci. 2019;117;458-533. https://psnet.ahrq.gov/issue/special-issue-resilience-engineering-and-high-reliability-organizations Resilience is an organizational characteristic that enables indivi…

7186. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34725/psn-pdf
      April 07, 2011 - Patient safety: what about the patient? April 7, 2011 Vincent C, Coulter A. Patient safety: what about the patient? Qual Saf Health Care. 2002;11(1):76-80. https://psnet.ahrq.gov/issue/patient-safety-what-about-patient In this perspective, Vincent and Coulter highlight the need for increased patient involvement in …

7187. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39876/psn-pdf
      July 02, 2014 - The anatomy of health care team training and the state of practice: a critical review. July 2, 2014 Weaver SJ, Lyons R, DiazGranados D, et al. The anatomy of health care team training and the state of practice: a critical review. Acad Med. 2010;85(11):1746-60. doi:10.1097/ACM.0b013e3181f2e907. https://psnet.ahrq.g…

7188. Primary Care and Patient Safety: Opportunities at the Interface | PSNet
      psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
      September 28, 2022 - In addition to its role in managing most common patient conditions, primary care can prevent harms such

7189. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44380/psn-pdf
      October 26, 2018 - From Safety-I to Safety-II: A White Paper. October 26, 2018 Hollnagel E, Wears RL, Braithwaite J. Middelfart, Denmark: Resilient Health Care Net; 2015. https://psnet.ahrq.gov/issue/safety-i-safety-ii-white-paper To enhance patient safety, researchers must consider complexity in health care settings. This white pape…

7190. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47943/psn-pdf
      May 20, 2019 - Governing the safety of artificial intelligence in healthcare. May 20, 2019 Macrae C. Governing the safety of artificial intelligence in healthcare. BMJ Qual Saf. 2019;28(6):495-498. doi:10.1136/bmjqs-2019-009484. https://psnet.ahrq.gov/issue/governing-safety-artificial-intelligence-healthcare The unintended risk…

7191. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42166/psn-pdf
      June 10, 2018 - Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. March 21, 2013;18:1-3. https://psnet.ahrq.gov/issue/drawn-curtains-muted-alarms-and-diverted-attention-lead-tragedy- postanesthesia-care-unit This n…

7192. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43043/psn-pdf
      September 19, 2016 - "Second victim" casualties and how physician leaders can help. September 19, 2016 MacLeod L. "Second victim" casualties and how physician leaders can help. Physician Exect. 2014;40(1):8- 12. https://psnet.ahrq.gov/issue/second-victim-casualties-and-how-physician-leaders-can-help Second victims are clinicians who …

7193. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47336/psn-pdf
      March 04, 2019 - "Saying sorry": some strategies for effective apology within the workplace. March 4, 2019 Cleary M, Lees D, Lopez V. "Saying sorry": some strategies for effective apology within the workplace. Issues Ment Health Nurs. 2018;39(11):980-982. doi:10.1080/01612840.2018.1507571. https://psnet.ahrq.gov/issue/saying-sorry…

7194. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865931/psn-pdf
      July 22, 2024 - Examining the Impact of Artificial Intelligence (AI) on Healthcare Safety (R18). July 22, 2024 Rockville, MD: Agency for Research and Quality; July 15, 2024. PA-24-261. https://psnet.ahrq.gov/issue/notice-intent-publish-funding-opportunity-announcement-examining-impact- artificial Health systems are increasingly …

7195. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46160/psn-pdf
      June 07, 2017 - ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults. June 7, 2017 Horsham, PA: Institute for Safe Medication Practices; May 2017. https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults Insulin is a widely used medication that can contribute to serious patien…

7196. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46519/psn-pdf
      December 22, 2018 - Delirium in hospitalized older adults. December 22, 2018 Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017;377(15):1456-1466. doi:10.1056/NEJMcp1605501. https://psnet.ahrq.gov/issue/delirium-hospitalized-older-adults Delirium is considered a patient safety problem that can be prevented with…

7197. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33927/psn-pdf
      June 23, 2015 - Errors, incidents and accidents in anaesthetic practice. June 23, 2015 Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care. 1993;21(5):506-19. https://psnet.ahrq.gov/issue/errors-incidents-and-accidents-anae…

7198. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46082/psn-pdf
      February 25, 2019 - The opioid crisis: can improving diagnosis help solve the problem? February 25, 2019 Carr S. ImproveDx. April 2017;4:1-4. https://psnet.ahrq.gov/issue/opioid-crisis-can-improving-diagnosis-help-solve-problem The opioid epidemic has been widely discussed, but little research has examined how misdiagnosis can contr…

7199. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40729/psn-pdf
      October 04, 2011 - Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008. October 4, 2011 Cassidy CJ, Smith AF, Arnot-Smith J. Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning Syste…

7200. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47085/psn-pdf
      June 06, 2018 - Medical Device Safety Action Plan: Protecting Patients, Promoting Public Health. June 6, 2018 Silver Spring, MD: US Food and Drug Administration; April 2018. https://psnet.ahrq.gov/issue/medical-device-safety-action-plan-protecting-patients-promoting-public-health Reliable use of medical devices is an important co…