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7241. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74763/psn-pdf
      June 25, 2021 - FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. June 25, 2021 Silver Springs, MD: US Food and Drug Administration: June 25, 2021. https://psnet.ahrq.gov/issue/fda-safety-communication-flexible-bronchoscopes-and-updated- recommendations-reprocessing Incomplete reproce…

7242. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838642/psn-pdf
      October 19, 2022 - Notes on healing after a missed diagnosis. October 19, 2022 Fleming EA. Notes on healing after a missed diagnosis. JAMA. 2022;328(13):1297-1298. doi:10.1001/jama.2022.15724. https://psnet.ahrq.gov/issue/notes-healing-after-missed-diagnosis Honest apology is known to support healing from medical error for clinician…

7243. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43752/psn-pdf
      January 21, 2015 - Organizational and social-psychological conditions in healthcare and their importance for patient and staff safety. A critical incident study among doctors and nurses. January 21, 2015 Eklöf M, Törner M, Pousette A. Organizational and social-psychological conditions in healthcare and their importance for patient …

7244. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37056/psn-pdf
      February 24, 2011 - Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay. February 24, 2011 O'Mahony S, Mazur E, Charney P, et al. Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of …

7245. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47089/psn-pdf
      May 09, 2018 - Leadership Survey: Immunization Against Burnout: Insights Report. May 9, 2018 Swensen S, Strongwater S, Mohta NS. NEJM Catalyst: Insights Report. April 12, 2018. https://psnet.ahrq.gov/issue/leadership-survey-immunization-against-burnout-insights-report Clinician burnout presents challenges to organizational and p…

7246. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44074/psn-pdf
      November 16, 2015 - Investigating Clinical Incidents in the NHS. November 16, 2015 Sixth Report of Session 2014–15. House of Commons Public Administration Select Committee. London, England: The Stationery Office; March 27, 2015. Publication HC 886. https://psnet.ahrq.gov/issue/investigating-clinical-incidents-nhs Applying evidence ge…

7247. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46876/psn-pdf
      August 15, 2018 - Design for patient safety: a systems-based risk identification framework. August 15, 2018 Simsekler MCE, Ward JR, Clarkson J. Design for patient safety: a systems-based risk identification framework. Ergonomics. 2018;61(8):1046-1064. doi:10.1080/00140139.2018.1437224. https://psnet.ahrq.gov/issue/design-patient-sa…

7248. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43889/psn-pdf
      February 11, 2015 - Data as a catalyst for change: stories from the frontlines. February 11, 2015 Siegal D, Ruoff G. Data as a catalyst for change: stories from the frontlines. J Healthc Risk Manag. 2015;34(3):18-25. doi:10.1002/jhrm.21161. https://psnet.ahrq.gov/issue/data-catalyst-change-stories-frontlines Analysis of malpractice c…

7249. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43166/psn-pdf
      May 07, 2014 - Are med school grads prepared to practice medicine? May 7, 2014 Angus S, Vu R, Halvorsen AJ, et al. What skills should new internal medicine interns have in july? A national survey of internal medicine residency program directors. Academic medicine : journal of the Association of American Medical Colleges. 2014;89(…

7250. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34100/psn-pdf
      February 09, 2011 - Safety of patients isolated for infection control. February 9, 2011 Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA. 2003;290(14):1899-1905. https://psnet.ahrq.gov/issue/safety-patients-isolated-infection-control This study discovered that patients isolated for coloniza…

7251. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43512/psn-pdf
      September 29, 2017 - Interruptions and multi-tasking: moving the research agenda in new directions. September 29, 2017 Westbrook JI. Interruptions and multi-tasking: moving the research agenda in new directions. BMJ Qual Saf. 2014;23(11):877-9. doi:10.1136/bmjqs-2014-003372. https://psnet.ahrq.gov/issue/interruptions-and-multi-tasking…

7252. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47381/psn-pdf
      April 03, 2019 - The role of the patient in patient safety: what can we learn from healthcare's history? April 3, 2019 Leistikow I, Huisman F. The role of the patient in patient safety: What can we learn from healthcare's history? J Patient Saf Risk Manag. 2018;23(4):139-141. doi:10.1177/2516043518791051. https://psnet.ahrq.gov/is…

7253. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47416/psn-pdf
      January 09, 2019 - Supervision, autonomy, and medical error in the teaching clinic. January 9, 2019 Cossman JP, Wang M, Fischer AA. Supervision, autonomy, and medical error in the teaching clinic. J Am Acad Dermatol. 2018;79(5):981-983. doi:10.1016/j.jaad.2017.12.033. https://psnet.ahrq.gov/issue/supervision-autonomy-and-medical-err…

7254. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45070/psn-pdf
      October 03, 2017 - When There's Harm in the Hospital: Can Transparency Replace "Deny and Defend"? October 3, 2017 National Health Policy Forum. Washington, DC: George Washington University. March 11, 2016. https://psnet.ahrq.gov/issue/when-theres-harm-hospital-can-transparency-replace-deny-and-defend This report provides the insight…

7255. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/847058/psn-pdf
      April 05, 2023 - Care Delivery within Community Mental Health Teams. April 5, 2023 Farnborough, UK: Healthcare Safety Investigation Branch; March 2023. https://psnet.ahrq.gov/issue/care-delivery-within-community-mental-health-teams Patient suicide is a sentinel event. This report examines a suicide incident that identified problems…

7256. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44093/psn-pdf
      April 29, 2015 - South Carolina medication error bill is dangerously off target. April 29, 2015 ISMP Medication Safety Alert! Acute Care Edition. April 9, 2015;20:1,4. https://psnet.ahrq.gov/issue/south-carolina-medication-error-bill-dangerously-target This newsletter article reports on issues related to a legislation, drafted in …

7257. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42679/psn-pdf
      October 23, 2013 - An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. October 23, 2013 Hettinger Z, Fairbanks RJ, Hegde S, et al. An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. J Healthc Risk …

7258. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47906/psn-pdf
      August 21, 2019 - Creating a just culture: the Ottawa Hospital's experience. August 21, 2019 Forster AJ, Hamilton S, Hayes T, et al. Creating a Just Culture: The Ottawa Hospital's experience. Healthc Manage Forum. 2019;32(5):266-271. doi:10.1177/0840470419853303. https://psnet.ahrq.gov/issue/creating-just-culture-ottawa-hospitals-ex…

7259. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72796/psn-pdf
      March 03, 2021 - Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. March 3, 2021 Jachan DE, Müller?Werdan U, Lahmann NA. Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. Nurs Open. 2021;8(2):755-765. doi:1…

7260. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50705/psn-pdf
      January 01, 2020 - Closing the loop with ambulatory staff on safety reports. December 4, 2019 Williams S, Fiumara K, Kachalia A, et al. Closing the Loop with Ambulatory Staff on Safety Reports. Jt Comm J Qual Saf. 2020;46(1):44-50. doi:10.1016/j.jcjq.2019.09.009. https://psnet.ahrq.gov/issue/closing-loop-ambulatory-staff-safety-repor…