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psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
September 01, 2007 - The nurses describe the fact that in the operating room they never witness from my generation of surgeons … But when I'm in the operating room or seeing a patient in the clinic or heading down to the ED, at that … Diagnostic Safety and Quality
April 26, 2023
Awareness of human factors in the operating
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - Organizations are pressured to maximize revenue by operating at, or near, saturation. … devices showed that junior and experienced clinicians alike routinely got "lost in menuspace" when operating … I don't doubt that in preventing surgical errors, operating on the wrong limb, and that kind of thing
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - recording or "black box" systems in commercial aircraft, which have recently been experimented with in operating … aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating … I can remember being in the operating room and watching surgeons do things that made no real sense rationally
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psnet.ahrq.gov/web-mm/feeling-no-pain
August 30, 2023 - Feeling No Pain
Citation Text:
Bogner MS. Feeling No Pain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - https://psnet.ahrq.gov//#table1
maintained by many organizations, and there are considerable costs to operating
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psnet.ahrq.gov/issue/measure-dx-implementing-pathways-discover-and-learn-diagnostic-errors
August 25, 2021 - Commentary
Measure Dx: implementing pathways to discover and learn from diagnostic errors.
Citation Text:
Bradford A, Shofer M, Singh H. Measure Dx: Implementing pathways to discover and learn from diagnostic errors. Int J Qual Health Care. 2022;34(3):mzac068. doi:10.1093/intqhc/mzac068.…
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psnet.ahrq.gov/issue/longer-shifts-hospital-nurses-higher-levels-burnout-and-patient-dissatisfaction
August 15, 2012 - Study
The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction.
Citation Text:
Stimpfel AW, Sloane DM, Aiken LH. The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Aff (Millwood). …
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psnet.ahrq.gov/issue/disclosure-programmes-us-inadequate-response-medical-error
October 25, 2023 - Commentary
Disclosure programmes in the US--an inadequate response to medical error.
Citation Text:
Handley GM. Disclosure programmes in the US—an inadequate response to medical error. BMJ. 2024;385:q1318. doi:10.1136/bmj.q1318.
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psnet.ahrq.gov/issue/toward-safer-practice-otology-report-15-years-clinical-negligence-claims
January 21, 2015 - Study
Toward safer practice in otology: a report on 15 years of clinical negligence claims.
Citation Text:
Mathew R, Asimacopoulos E, Valentine P. Toward safer practice in otology: a report on 15 years of clinical negligence claims. Laryngoscope. 2011;121(10):2214-9. doi:10.1002/lary.2…
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psnet.ahrq.gov/issue/fostering-ethical-conduct-through-psychological-safety
March 30, 2022 - Newspaper/Magazine Article
Fostering ethical conduct through psychological safety.
Citation Text:
Fostering ethical conduct through psychological safety. Ferrere A, Rider C, Renerte B et al. Sloan Manag Rev. Summer 2022;39-43.
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psnet.ahrq.gov/node/866621/psn-pdf
August 28, 2024 - Application of Safety-II Principles
August 28, 2024
Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/application-safety-ii-principles
Traditional approaches to patient safety have often been reactive rather than proactive, seeki…
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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - They were operating not under the promise of shared gain and reward but under the threat of punishment
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psnet.ahrq.gov/node/33863/psn-pdf
August 01, 2018 - Here you take the actual CT scan of
the patient you're operating on and that is then overlaid on the … to practice on the actual patient anatomy and physiology before they do it on that patient in the
operating
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psnet.ahrq.gov/issue/relationship-between-patient-complaints-and-surgical-complications
January 05, 2011 - Study
Relationship between patient complaints and surgical complications.
Citation Text:
Murff HJ, France DJ, Blackford J, et al. Relationship between patient complaints and surgical complications. Qual Saf Health Care. 2006;15(1):13-6.
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psnet.ahrq.gov/issue/telehealth-safety-framework-addressing-new-frontier-patient-safety
December 21, 2022 - Commentary
Telehealth safety framework: addressing a new frontier in patient safety.
Citation Text:
Gomes KM, Apathy N, Krevat SA, et al. Telehealth safety framework: addressing a new frontier in patient safety. J Patient Saf. 2024;20(5):358-359. doi:10.1097/pts.0000000000001243.
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psnet.ahrq.gov/issue/predictors-unit-level-medication-administration-accuracy-microsystem-impacts-medication
October 06, 2016 - Study
Predictors of unit-level medication administration accuracy: microsystem impacts on medication safety.
Citation Text:
Donaldson N, Aydin C, Fridman M. Predictors of unit-level medication administration accuracy: microsystem impacts on medication safety. J Nurs Adm. 2014;44(6):353-6…
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psnet.ahrq.gov/issue/introducing-safety-score-audit-staff-member-and-patient-safety
April 16, 2014 - Commentary
Introducing the safety score audit for staff member and patient safety.
Citation Text:
Sinnott M, Eley R, Winch S. Introducing the safety score audit for staff member and patient safety. AORN J. 2014;100(1):91-5. doi:10.1016/j.aorn.2014.05.006.
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psnet.ahrq.gov/issue/sensitivity-adverse-event-cost-estimates-diagnostic-coding-error
March 03, 2011 - Study
The sensitivity of adverse event cost estimates to diagnostic coding error.
Citation Text:
Wardle G, Wodchis WP, Laporte A, et al. The sensitivity of adverse event cost estimates to diagnostic coding error. Health Serv Res. 2012;47(3 Pt 1):984-1007. doi:10.1111/j.1475-6773.2011.0…
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psnet.ahrq.gov/issue/impact-rvu-based-compensation-patient-safety-outcomes-outpatient-otolaryngology-procedures
October 19, 2022 - Study
The impact of RVU-based compensation on patient safety outcomes in outpatient otolaryngology procedures.
Citation Text:
Stanisce L, Ahmad N, Deckard N, et al. The Impact of RVU-Based Compensation on Patient Safety Outcomes in Outpatient Otolaryngology Procedures. Otolaryngol Head N…
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psnet.ahrq.gov/issue/pay-practices-and-safety-organizing-evidence-hospital-nursing-units
December 21, 2017 - Study
Pay practices and safety organizing: evidence from hospital nursing units.
Citation Text:
Conroy SA, Vogus TJ. Pay practices and safety organizing: evidence from hospital nursing units. Health Care Manage Rev. 2023;49(1):68-73. doi:10.1097/hmr.0000000000000392.
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