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psnet.ahrq.gov/node/837980/psn-pdf
March 21, 2024 - Diagnostic errors.
March 21, 2024
Raffel K, Ranji S. UpToDate. February 8, 2024.
https://psnet.ahrq.gov/issue/diagnostic-errors
Diagnostic mistakes are common contributors to preventable patient harm. This review highlights primary
areas of diagnostic error concerns (vascular events, infections, and cancers) …
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psnet.ahrq.gov/node/41156/psn-pdf
March 02, 2012 - The implementation of a perioperative checklist increases
patients' perioperative safety and staff satisfaction.
March 2, 2012
Böhmer AB, Wappler F, Tinschmann T, et al. The implementation of a perioperative checklist increases
patients' perioperative safety and staff satisfaction. Acta Anaesthesiol Scand. 2012;56(…
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psnet.ahrq.gov/node/38630/psn-pdf
May 13, 2009 - Seasoned surgeons assessed in a laparoscopic surgical
crisis.
May 13, 2009
Powers K, Rehrig ST, Schwaitzberg SD, et al. Seasoned surgeons assessed in a laparoscopic surgical
crisis. J Gastrointest Surg. 2009;13(5):994-1003. doi:10.1007/s11605-009-0802-1.
https://psnet.ahrq.gov/issue/seasoned-surgeons-assessed-lapa…
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psnet.ahrq.gov/node/40966/psn-pdf
November 30, 2011 - Toward safer practice in otology: a report on 15 years of
clinical negligence claims.
November 30, 2011
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.22136.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/50577/psn-pdf
October 23, 2019 - Medicare's Oversight of Ambulatory Surgery Centers
Report.
October 23, 2019
Washington, DC: Office of the Inspector General; September 2019. Report No. OEI-01-15-00400.
https://psnet.ahrq.gov/issue/medicares-oversight-ambulatory-surgery-centers-report
Ambulatory surgery centers (ASC) play an increasing role in com…
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psnet.ahrq.gov/node/848384/psn-pdf
May 03, 2023 - Roadmap to Health Care Safety for Massachusetts.
May 3, 2023
Massachusetts Healthcare Safety and Quality Consortium. Boston, MA: Betsy Lehman Center for Patient
Safety; April 2023.
https://psnet.ahrq.gov/issue/roadmap-health-care-safety-massachusetts
Collective engagement and focus are required to attain large sys…
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psnet.ahrq.gov/node/45003/psn-pdf
July 18, 2016 - Effect of surgical safety checklists on pediatric surgical
complications in Ontario.
July 18, 2016
O'Leary JD, Wijeysundera DN, Crawford MW. Effect of surgical safety checklists on pediatric surgical
complications in Ontario. CMAJ. 2016;188(9):E191-E198. doi:10.1503/cmaj.151333.
https://psnet.ahrq.gov/issue/effect…
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psnet.ahrq.gov/node/40897/psn-pdf
November 02, 2011 - Infrequent physician use of implantable cardioverter-
defibrillators risks patient safety.
November 2, 2011
Lyman S, Sedrakyan A, Do H, et al. Infrequent physician use of implantable cardioverter-defibrillators risks
patient safety. Heart. 2011;97(20):1655-60. doi:10.1136/hrt.2011.226282.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/39295/psn-pdf
January 03, 2017 - The Veterans Affairs shift change physician-to-physician
handoff project.
January 3, 2017
Anderson J, Shroff D, Curtis A, et al. The Veterans Affairs shift change physician-to-physician handoff
project. Jt Comm J Qual Patient Saf. 2010;36(2):62-71.
https://psnet.ahrq.gov/issue/veterans-affairs-shift-change-physici…
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psnet.ahrq.gov/node/47829/psn-pdf
March 27, 2019 - The impact of internal service quality on preventable
adverse events in hospitals.
March 27, 2019
Zheng S, Tucker AL, Ren ZJ, et al. The Impact of Internal Service Quality on Preventable Adverse Events
in Hospitals. Production Operations Manag. 2017;27(12):2201-2212. doi:10.1111/poms.12758.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/46885/psn-pdf
March 20, 2018 - Opioid prescribing patterns and complications in the
dermatology Medicare population.
March 20, 2018
Cao S, Karmouta R, Li DG, et al. Opioid Prescribing Patterns and Complications in the Dermatology
Medicare Population. JAMA Dermatol. 2018;154(3):317-322. doi:10.1001/jamadermatol.2017.5835.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/836720/psn-pdf
March 09, 2022 - Reliability, uncertainty and the management of error: new
perspectives in the COVID-19 era.
March 9, 2022
Schulman PR. Reliability, uncertainty and the management of error: new perspectives in the COVID?19
era. J Contingencies Crisis Manage. 2022;30(1):92-101. doi:10.1111/1468-5973.12356.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/73861/psn-pdf
September 22, 2021 - Bringing the clinical laboratory into the strategy to
advance diagnostic excellence.
September 22, 2021
Lubin IM, Astles J R, Shahangian S, et al. Bringing the clinical laboratory into the strategy to advance
diagnostic excellence. Diagnosis (Berl). 2021;8(3):281-294. doi:10.1515/dx-2020-0119.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/34930/psn-pdf
April 06, 2011 - "Going solid": a model of system dynamics and
consequences for patient safety.
April 6, 2011
Cook R, Rasmussen J. "Going solid": a model of system dynamics and consequences for patient safety.
Qual Saf Health Care. 2005;14(2):130-4.
https://psnet.ahrq.gov/issue/going-solid-model-system-dynamics-and-consequences-pa…
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psnet.ahrq.gov/node/867451/psn-pdf
January 21, 2025 - Engineering Safety into Practice through Implementation
of the EHR SAFER Guides.
January 8, 2025
National Action Alliance for Patient and Workforce Safety. Engineering Safety into Practice through
Implementation of the EHR SAFER Guides. January 21, 2025, 12:00 - 1:00 PM (eastern).
https://psnet.ahrq.gov/issue/engi…
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psnet.ahrq.gov/node/837747/psn-pdf
July 27, 2022 - Measure Dx: A Resource to Identify, Analyze, and Learn
from Diagnostic Safety Events.
July 27, 2022
Rockville, MD: Agency for Healthcare Research and Quality; July 2022. AHRQ Publication No. 22-
0038.
https://psnet.ahrq.gov/issue/measure-dx-resource-identify-analyze-and-learn-diagnostic-safety-events
Diagno…
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psnet.ahrq.gov/node/72585/psn-pdf
December 16, 2020 - Think health care workers are tested often for the
Coronavirus? Think again.
December 16, 2020
Wamsley L. National Public Radio and WBUR. December 7, 2020.
https://psnet.ahrq.gov/issue/think-health-care-workers-are-tested-often-coronavirus-think-again
Testing for COVID-19 is a core public safety strategy for …
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psnet.ahrq.gov/node/60696/psn-pdf
July 15, 2020 - Culture as a Cure: Assessments of Patient Safety Culture
in OECD Countries.
July 15, 2020
de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation
and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 119.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/60897/psn-pdf
January 01, 2022 - Association between surgeon technical skills and patient
outcomes.
September 9, 2020
Stulberg JJ, Huang R, Kreutzer L, et al. Association Between Surgeon Technical Skills and Patient
Outcomes. JAMA Surg. 2022;157(3):219-220. doi:10.1001/jamasurg.2020.3007.
https://psnet.ahrq.gov/issue/association-between-surgeon-t…
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psnet.ahrq.gov/node/47289/psn-pdf
October 24, 2018 - ASHP guidelines on managing drug product shortages.
October 24, 2018
Fox ER, McLaughlin MM. ASHP guidelines on managing drug product shortages. Am J Health Syst Pharm.
2018;75(21):1742-1750. doi:10.2146/ajhp180441.
https://psnet.ahrq.gov/issue/ashp-guidelines-managing-drug-product-shortages
Drug shortages are a pe…