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psnet.ahrq.gov/node/42031/psn-pdf
February 06, 2013 - Assessing diagnostic reasoning: a consensus statement
summarizing theory, practice, and future needs.
February 6, 2013
Ilgen JS, Humbert AJ, Kuhn G, et al. Assessing diagnostic reasoning: a consensus statement summarizing
theory, practice, and future needs. Acad Emerg Med. 2012;19(12):1454-61. doi:10.1111/acem.1203…
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psnet.ahrq.gov/node/43282/psn-pdf
April 25, 2016 - Understanding the effect of resident duty hour reform: a
qualitative study.
April 25, 2016
Pattani R, Wu PE, Dhalla IA. Resident duty hours in Canada: past, present and future. Can Med Assoc J.
2014;186(10). doi:10.1503/cmaj.131053.
https://psnet.ahrq.gov/issue/understanding-effect-resident-duty-hour-reform-qualit…
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psnet.ahrq.gov/node/38707/psn-pdf
June 17, 2009 - Doctors' views of attitudes towards peer medical error.
June 17, 2009
Asghari F, Fotouhi A, Jafarian A. Doctors' views of attitudes towards peer medical error. Qual Saf Health
Care. 2009;18(3):209-12. doi:10.1136/qshc.2007.025015.
https://psnet.ahrq.gov/issue/doctors-views-attitudes-towards-peer-medical-error
The …
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psnet.ahrq.gov/node/73660/psn-pdf
September 01, 2021 - Hospital inpatient falls across clinical departments.
September 1, 2021
Mikos M, Banas T, Czerw A, et al. Hospital inpatient falls across clinical departments. Int J Environ Res
Public Health. 2021;18(15):8167. doi:10.3390/ijerph18158167.
https://psnet.ahrq.gov/issue/hospital-inpatient-falls-across-clinical-departm…
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psnet.ahrq.gov/node/42485/psn-pdf
August 14, 2013 - Impact of individual and team features of patient safety
climate: a survey in family practices.
August 14, 2013
Hoffmann B, Miessner C, Albay Z, et al. Impact of individual and team features of patient safety climate: a
survey in family practices. Ann Fam Med. 2013;11(4):355-62. doi:10.1370/afm.1500.
https://psnet…
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psnet.ahrq.gov/node/837766/psn-pdf
August 03, 2022 - Iatrogenesis in the context of residential dementia care: a
concept analysis.
August 3, 2022
Morris P, McCloskey R, Bulman D. Iatrogenesis in the context of residential dementia care: a concept
analysis. Innov Aging. 2022;6(4):iagc028. doi:10.1093/geroni/igac028.
https://psnet.ahrq.gov/issue/iatrogenesis-context-r…
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psnet.ahrq.gov/node/40670/psn-pdf
August 03, 2011 - ED revamp: team approach to care reduces errors, boosts
patient and clinician satisfaction.
August 3, 2011
ED revamp: team approach to care reduces errors, boosts patient and clinician satisfaction. ED
management : the monthly update on emergency department management. 2011;23(7):78-80.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/73477/psn-pdf
July 07, 2021 - Closing Death’s Door: Legal Innovations to End the
Epidemic of Healthcare Harm.
July 7, 2021
Saks M, Landsman S. New York, NY: Oxford University Press; 2021. ISBN: 9780190667986.
https://psnet.ahrq.gov/issue/closing-deaths-door-legal-innovations-end-epidemic-healthcare-harm
A weave of systemic factors c…
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psnet.ahrq.gov/node/44546/psn-pdf
December 14, 2016 - Diagnostic delays in paediatric stroke.
December 14, 2016
Mallick AA, Ganesan V, Kirkham FJ, et al. Diagnostic delays in paediatric stroke. J Neurol Neurosurg
Psychiatry. 2015;86(8):917-21. doi:10.1136/jnnp-2014-309188.
https://psnet.ahrq.gov/issue/diagnostic-delays-paediatric-stroke
Diagnostic error is a rapidly …
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psnet.ahrq.gov/node/850936/psn-pdf
June 29, 2023 - After Roe: Challenges in the Provision of Lifesaving Care.
June 21, 2023
Washington DC; National Academies of Science, Engineering and Medicine: June 29, 2023.
https://psnet.ahrq.gov/issue/after-roe-challenges-provision-lifesaving-care
Delay in access to obstetric care hinders safe treatment for patients experienci…
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psnet.ahrq.gov/node/838327/psn-pdf
October 12, 2022 - Diagnoses Without Names: Challenges for Medical Care,
Research, and Policy.
October 12, 2022
Lockshin MD, Crow MK, Barbhaiya M, eds. Springer Nature: Cham, Switzerland; 2022. ISBN
9783031049347.
https://psnet.ahrq.gov/issue/diagnoses-without-names-challenges-medical-care-research-and-policy
Clinicians…
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psnet.ahrq.gov/node/43813/psn-pdf
January 20, 2015 - Adverse events in patients with return emergency
department visits.
January 20, 2015
Calder LA, Pozgay A, Riff S, et al. Adverse events in patients with return emergency department visits.
BMJ Qual Saf. 2015;24(2):142-148. doi:10.1136/bmjqs-2014-003194.
https://psnet.ahrq.gov/issue/adverse-events-patients-return-e…
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psnet.ahrq.gov/node/33933/psn-pdf
March 02, 2011 - Patient safety and medical malpractice: a case study.
March 2, 2011
Brennan TA, Mello MM. Patient safety and medical malpractice: a case study. Ann Intern Med.
2003;139(4):267-73.
https://psnet.ahrq.gov/issue/patient-safety-and-medical-malpractice-case-study
This case study discusses the ongoing challenges in bala…
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psnet.ahrq.gov/node/46059/psn-pdf
July 11, 2017 - Pathologists' perspectives on disclosing harmful
pathology error.
July 11, 2017
Dintzis SM, Clennon EK, Prouty CD, et al. Pathologists' Perspectives on Disclosing Harmful Pathology
Error. Arch Pathol Lab Med. 2017;141(6):841-845. doi:10.5858/arpa.2016-0136-OA.
https://psnet.ahrq.gov/issue/pathologists-perspectives…
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psnet.ahrq.gov/node/38125/psn-pdf
January 11, 2017 - 2008 John M. Eisenberg Patient Safety and Quality
Awards.
January 11, 2017
Jt Comm J Qual Patient Saf. 2008;34(12):691-712.
https://psnet.ahrq.gov/issue/2008-john-m-eisenberg-patient-safety-and-quality-awards
The Eisenberg Award honors individuals and organizations who have made vital accomplishments in
improving…
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psnet.ahrq.gov/node/41421/psn-pdf
November 26, 2014 - "Learning by Doing"—resident perspectives on
developing competency in high-quality discharge care.
November 26, 2014
Greysen R, Schiliro D, Curry LA, et al. "Learning by doing"--resident perspectives on developing
competency in high-quality discharge care. J Gen Intern Med. 2012;27(9):1188-94. doi:10.1007/s11606-
…
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psnet.ahrq.gov/node/855104/psn-pdf
November 08, 2023 - Healthcare wants to fly as high as the aviation industry.
Can it?
November 8, 2023
Twenter P. Becker's Clinical Leadership. October 30, 2023.
https://psnet.ahrq.gov/issue/healthcare-wants-fly-high-aviation-industry-can-it
Health care has long held commercial aviation as a beacon to guide patient safety improv…
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psnet.ahrq.gov/node/34737/psn-pdf
November 19, 2015 - First, Do No Harm Part 1: A Case Study of Systems
Failure.
November 19, 2015
Chicago: Partnership for Patient Safety, Harvard Risk Management Foundation; 2000.
https://psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure
This video, produced by the Partnership for Patient Safety and the Harvard …
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psnet.ahrq.gov/node/863003/psn-pdf
February 21, 2024 - Positive Patient Identification.
February 21, 2024
Healthcare Safety Investigation Branch (HSIB), Dorset, UK: Health Services Safety
Investigations Body; February 2024.
https://psnet.ahrq.gov/issue/positive-patient-identification
Patient misidentification can result in medication administration errors, …
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psnet.ahrq.gov/node/46943/psn-pdf
November 16, 2018 - A piece of my mind. The art of constructive worrying.
November 16, 2018
John CC. The Art of Constructive Worrying. JAMA. 2018;319(22):2273-2274. doi:10.1001/jama.2018.6670.
https://psnet.ahrq.gov/issue/piece-my-mind-art-constructive-worrying
Both organizational culture and individual accountability are key to admit…