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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34691/psn-pdf
    May 18, 2016 - Error in medicine. May 18, 2016 Leape L. Error in medicine. JAMA. 1994;272(23):1851-1857. https://psnet.ahrq.gov/issue/error-medicine Leape discusses how traditional methods of error reduction in medicine have focused on individual performance rather than on the systems in which individuals operate. With reference…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74231/psn-pdf
    January 12, 2022 - Quality and safety in hospital pediatrics during COVID-19: a national qualitative study. January 12, 2022 De Angulo NR, Penwill N, Pathak PR, et al. Quality and safety in hospital pediatrics during COVID-19: a national qualitative study. Hosp Pediatr. 2022;12(1):e2021006115. doi:10.1542/hpeds.2021-006115. https://…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46278/psn-pdf
    July 19, 2017 - The opioid epidemic: what can surgeons do about it? July 19, 2017 Saluja S, Selzer D, Meara JG, et al. Bull Am Coll Surg. 2017;102(7):13-18. https://psnet.ahrq.gov/issue/opioid-epidemic-what-can-surgeons-do-about-it Surgeons often prescribe opioids for patients after procedures, so they are in a key position to ass…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37255/psn-pdf
    December 19, 2011 - Communicating in the "gray zone": perceptions about emergency physician-hospitalist handoffs and patient safety. December 19, 2011 Apker J, Mallak LA, Gibson SC. Communicating in the "gray zone": perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14(10):884-94. htt…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43047/psn-pdf
    August 02, 2015 - Hospital readmission after noncardiac surgery: the role of major complications. August 2, 2015 Glance LG, Kellermann AL, Osler T, et al. Hospital readmission after noncardiac surgery: the role of major complications. JAMA Surg. 2014;149(5):439-45. https://psnet.ahrq.gov/issue/hospital-readmission-after-noncardiac-…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43284/psn-pdf
    November 28, 2016 - Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff. November 28, 2016 Corbally MT, Tierney E. Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff. Int J Pediatr. 2014;2014:791490. doi:10.1155/2014/791490. htt…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42579/psn-pdf
    November 18, 2013 - Surgical safety checklist compliance: a job done poorly! November 18, 2013 Sparks EA, Wehbe-Janek H, Johnson RL, et al. Surgical Safety Checklist compliance: a job done poorly!. J Am Coll Surg. 2013;217(5):867-73.e1-3. doi:10.1016/j.jamcollsurg.2013.07.393. https://psnet.ahrq.gov/issue/surgical-safety-checklist-com…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34800/psn-pdf
    December 23, 2008 - A classification system for incidents and accidents in the health-care system. December 23, 2008 Runciman WB, Helps SC, Sexton EJ, et al. A classification for incidents and accidents in the health-care system. J Qual Clin Pract. 1998;18(3):199-211. https://psnet.ahrq.gov/issue/classification-system-incidents-and-a…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40270/psn-pdf
    March 09, 2011 - Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery. March 9, 2011 Latimer K, Pendleton C, Olivi A, et al. Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery. Arch Surg. 2011;146(2):226-32. doi:10.1001/archsurg.2…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865719/psn-pdf
    May 01, 2024 - High reliability pediatric heart centers: always working toward getting better. May 1, 2024 Torzone A, Birely A. High reliability pediatric heart centers: always working toward getting better. Curr Opin Cardiol. 2024;39(4):356-363. doi:10.1097/hco.0000000000001143. https://psnet.ahrq.gov/issue/high-reliability-ped…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74067/psn-pdf
    November 10, 2021 - Conflict resolution: applying aviation crew resource management in healthcare. November 10, 2021 Braverman A. Conflict resolution: applying aviation crew resource management in healthcare. Nurs Manage. 2021;52(9):30-34. doi:10.1097/01.numa.0000771740.79361.1c. https://psnet.ahrq.gov/issue/conflict-resolution-apply…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41358/psn-pdf
    July 06, 2012 - Safety skills training for surgeons: a half-day intervention improves knowledge, attitudes and awareness of patient safety. July 6, 2012 Arora S, Sevdalis N, Ahmed M, et al. Safety skills training for surgeons: A half-day intervention improves knowledge, attitudes and awareness of patient safety. Surgery. 2012;152…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46909/psn-pdf
    August 01, 2018 - Guidance on Safe Medical Staffing: Report of a Working Party. August 1, 2018 London, UK: Royal College of Physicians; 2018. ISBN: 9781860167270. https://psnet.ahrq.gov/issue/guidance-safe-medical-staffing-report-working-party Lack of appropriate staffing can diminish the safety and effectiveness of medical service…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45369/psn-pdf
    October 29, 2017 - The aging physician and the medical profession: a review. October 29, 2017 Dellinger P, Pellegrini CA, Gallagher TH. The Aging Physician and the Medical Profession: A Review. JAMA Surg. 2017;152(10):967-971. doi:10.1001/jamasurg.2017.2342. https://psnet.ahrq.gov/issue/aging-physician-and-medical-profession-review …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45188/psn-pdf
    June 01, 2016 - Reporting and second-order problem solving can turn short-term fixes into long-term remedies. June 1, 2016 ISMP Medication Safety Alert! Acute Care Edition. May 19, 2016;21:1-4. https://psnet.ahrq.gov/issue/reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long- term-remedies Workarounds are pr…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40576/psn-pdf
    July 06, 2011 - A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non- routine events, teamwork and patient outcomes. July 6, 2011 Schraagen JM, Schouten T, Smit M, et al. A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-rou…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866443/psn-pdf
    August 07, 2024 - Cultivate discussions in a psychologically safe workplace: part 1 and part II. August 7, 2024 ISMP Medication Safety Alert! Acute Care. July 11, 2024;29;(14):1-3; July 25, 2024;29(15):1-5. https://psnet.ahrq.gov/issue/cultivate-discussions-psychologically-safe-workplace-part-1-and-part-ii Psychological safety is c…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837516/psn-pdf
    June 22, 2022 - Fostering ethical conduct through psychological safety. June 22, 2022 Ferrere A, Rider C, Renerte B et al. Sloan Manag Rev. Summer 2022;39-43. https://psnet.ahrq.gov/issue/fostering-ethical-conduct-through-psychological-safety A baseline expectation in a safe organization is that employees feel comfortable and supp…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837660/psn-pdf
    July 08, 2022 - Allow adequate time for pre-op assessment Turnover times in operating and procedure rooms are keenly … monitored by hospital administrators to maximize operating room utilization, and thus to accommodate
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33710/psn-pdf
    May 01, 2011 - The patient began to bleed, and bled out in the operating room. … We now have policies and standard operating procedures for handling the patients.

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