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psnet.ahrq.gov/issue/healthcare-associated-adverse-events-alternate-level-care-patients-awaiting-long-term-care
March 17, 2021 - Study
Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital.
Citation Text:
Lim Fat GJ, Gopaul A, Pananos AD, et al. Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital. Geriat…
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psnet.ahrq.gov/issue/association-between-implementation-medical-team-training-program-and-surgical-mortality
December 21, 2014 - Study
Classic
Association between implementation of a medical team training program and surgical mortality.
Citation Text:
Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2…
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psnet.ahrq.gov/issue/program-provide-clinicians-feedback-their-diagnostic-performance-learning-health-system
October 12, 2022 - Study
A program to provide clinicians with feedback on their diagnostic performance in a learning health system.
Citation Text:
Meyer AND, Upadhyay DK, Collins CA, et al. A program to provide clinicians with feedback on their diagnostic performance in a learning health system. Jt Comm J …
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psnet.ahrq.gov/issue/effects-teamwork-training-adverse-outcomes-and-process-care-labor-and-delivery-randomized
January 10, 2017 - Study
Classic
Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial.
Citation Text:
Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care …
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psnet.ahrq.gov/issue/physicians-views-interventions-reduce-medical-errors-does-evidence-effectiveness-matter
February 18, 2011 - Study
Physicians' views of interventions to reduce medical errors: does evidence of effectiveness matter?
Citation Text:
Rosen AB, Blendon RJ, DesRoches CM, et al. Physicians' views of interventions to reduce medical errors: does evidence of effectiveness matter? Acad Med. 2005;80(2):1…
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psnet.ahrq.gov/issue/systematic-review-exploring-content-and-outcomes-interventions-improve-psychological-safety
October 28, 2020 - Review
Classic
A systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behaviour.
Citation Text:
O’Donovan R, McAuliffe E. A systematic review exploring the content and outcomes of interventi…
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psnet.ahrq.gov/issue/effect-availability-bias-and-reflective-reasoning-diagnostic-accuracy-among-internal-medicine
March 12, 2014 - Study
Classic
Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents.
Citation Text:
Mamede S, Van Gog T, Van den Berge K, et al. Effect of availability bias and reflective reasoning on diagnostic accuracy a…
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psnet.ahrq.gov/issue/analysis-lawsuits-related-diagnostic-errors-point-care-ultrasound-internal-medicine
October 27, 2021 - Study
Analysis of lawsuits related to diagnostic errors from point-of-care ultrasound in internal medicine, paediatrics, family medicine and critical care in the USA.
Citation Text:
Reaume M, Farishta M, Costello JA, et al. Analysis of lawsuits related to diagnostic errors from point-of-…
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psnet.ahrq.gov/issue/evaluation-effectiveness-and-safety-pharmacist-independent-prescribers-care-homes-cluster
December 15, 2021 - Study
Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial.
Citation Text:
Holland R, Bond CM, Alldred DP, et al. Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster…
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psnet.ahrq.gov/issue/short-and-long-term-effects-electronic-medication-management-system-paediatric-prescribing
August 28, 2024 - Study
Short- and long-term effects of an electronic medication management system on paediatric prescribing errors.
Citation Text:
Westbrook JI, Li L, Raban MZ, et al. Short- and long-term effects of an electronic medication management system on paediatric prescribing errors. NPJ Digit Me…
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psnet.ahrq.gov/issue/teamwork-associated-reduced-hospital-staff-burnout-military-treatment-facilities-findings
July 31, 2013 - Study
Teamwork is associated with reduced hospital staff burnout at military treatment facilities: findings from the 2019 Department of Defense Patient Safety Culture Survey.
Citation Text:
Godby Vail S, Dierst-Davies R, Kogut D, et al. Teamwork is associated with reduced hospital staff …
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psnet.ahrq.gov/issue/exploring-factors-promote-or-diminish-psychologically-safe-environment-qualitative-interview
September 01, 2021 - Study
Exploring the factors that promote or diminish a psychologically safe environment: a qualitative interview study with critical care staff.
Citation Text:
Grailey K, Leon-Villapalos C, Murray E, et al. Exploring the factors that promote or diminish a psychologically safe environment…
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psnet.ahrq.gov/issue/nhs-learning-deaths-reports-qualitative-and-quantitative-document-analysis-first-year
February 22, 2023 - Study
NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme.
Citation Text:
Brummell Z, Vindrola-Padros C, Braun D, et al. NHS ‘Learning from Deaths’ reports: a qualitative and quantitative documen…
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psnet.ahrq.gov/issue/exploring-patient-safety-outcomes-people-learning-disabilities-acute-hospital-settings
March 02, 2022 - Review
Exploring patient safety outcomes for people with learning disabilities in acute hospital settings: a scoping review.
Citation Text:
Louch G, Albutt AK, Harlow-Trigg J, et al. Exploring patient safety outcomes for people with learning disabilities in acute hospital settings: a sco…
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psnet.ahrq.gov/issue/contribution-staffing-medication-administration-errors-text-mining-analysis-incident-report
December 21, 2022 - Study
The contribution of staffing to medication administration errors: a text mining analysis of incident report data.
Citation Text:
Härkänen M, Vehviläinen‐Julkunen K, Murrells T, et al. The Contribution of Staffing to Medication Administration Errors: A Text Mining Analysis of Incide…
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psnet.ahrq.gov/issue/hidden-cost-regulation-administrative-cost-reporting-serious-reportable-events
December 02, 2020 - Study
The hidden cost of regulation: the administrative cost of reporting serious reportable events.
Citation Text:
Blanchfield BB, Acharya B, Mort E. The Hidden Cost of Regulation: The Administrative Cost of Reporting Serious Reportable Events. Jt Comm J Qual Patient Saf. 2018;44(4):212…
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psnet.ahrq.gov/node/846935/psn-pdf
March 29, 2023 - Maternal Safety and Perinatal Mental Health
March 29, 2023
Allen C, Van CM, Mossburg S. Maternal Safety and Perinatal Mental Health . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
Maternal patient safety is a critical aspect of healthcare given the complex pr…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - Spotlight Case July 2008
Spotlight Case
Emergency Error
1
2
Source and Credits
This presentation is based on the June 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
April 01, 2008 - Patient Safety and the Evolution of WebM&M and PSNet
September 1, 2019
View more articles from the same authors.
Citation Text:
Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. Rockville (MD): Agency for Healthcare Resea…
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psnet.ahrq.gov/node/865418/psn-pdf
March 27, 2024 - Cybersecurity and How to Maintain Patient Safety
March 27, 2024
Pelletreau B, Riggi J, Gale B, et al. Cybersecurity and How to Maintain Patient Safety. PSNet [internet].
2024.
https://psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
Introduction
The integration of information technology (I…