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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…
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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://…
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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…
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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…
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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-…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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
…
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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…
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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…
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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…
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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…
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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
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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.