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psnet.ahrq.gov/node/35023/psn-pdf
March 04, 2011 - Building a framework for trust: critical event analysis of
deaths in surgical care.
March 4, 2011
Thompson A, Stonebridge PA. Building a framework for trust: critical event analysis of deaths in surgical
care. BMJ. 2005;330(7500):1139-42.
https://psnet.ahrq.gov/issue/building-framework-trust-critical-event-analysi…
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psnet.ahrq.gov/node/859353/psn-pdf
December 20, 2023 - Global State of Patient Safety 2023.
December 20, 2023
Illingworth J, Shaw A, Fernandez et al. London UK: Imperial College London; 2023.
https://psnet.ahrq.gov/issue/global-state-patient-safety-2023
Patient safety data can support learning health systems and worldwide improvement. This report discusses
a set of in…
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psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
October 01, 2007 - organization would respond to a given behavior by a clinician (e.g., bringing unauthorized equipment into the operating … How would our organization respond to a surgeon who uses an unauthorized piece of equipment in the operating
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - In Conversation with Timothy Vogus about High
Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization
(HRO) Principles and Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/persp…
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psnet.ahrq.gov/node/74022/psn-pdf
March 01, 2021 - Community pharmacies are sometimes equated to retail pharmacies, operating out of both large and small
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psnet.ahrq.gov/node/72616/psn-pdf
December 22, 2020 - the evaluation of harms is that dentistry is a very
siloed profession, with the majority of dentists operating
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psnet.ahrq.gov/node/33648/psn-pdf
March 01, 2007 - who hears you and says, I need to
slow down, and then goes back into the machine and the machine is operating
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - They took her to the operating room (OR) together for suspected necrotizing fasciitis.
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psnet.ahrq.gov/node/49499/psn-pdf
December 02, 2020 - Operating under
this time pressure, the temptation arises to quickly come to a diagnosis, as the first
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psnet.ahrq.gov/node/847043/psn-pdf
April 05, 2023 - An evidence synthesis on perioperative handoffs: a call
for balanced sociotechnical solutions.
April 5, 2023
Abraham J, Duffy C, Kandasamy M, et al. An evidence synthesis on perioperative handoffs: a call for
balanced sociotechnical solutions. Int J Med Inform. 2023;174:105038. doi:10.1016/j.ijmedinf.2023.105038.
…
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psnet.ahrq.gov/node/836752/psn-pdf
March 16, 2022 - The necessary leadership skillsets for the high-reliability
organization framework adoption within acute healthcare
organizations.
March 16, 2022
Logan?Athmer AL. The necessary leadership skillsets for the high?reliability organization framework
adoption within acute healthcare organizations. J Healthc Risk Manag.…
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psnet.ahrq.gov/node/37309/psn-pdf
January 05, 2012 - Adverse drug events in hospitalized cardiac patients.
January 5, 2012
Fanikos J, Cina J, Baroletti S, et al. Adverse drug events in hospitalized cardiac patients. Am J Cardiol.
2007;100(9):1465-9.
https://psnet.ahrq.gov/issue/adverse-drug-events-hospitalized-cardiac-patients
This study noted two adverse drug event…
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psnet.ahrq.gov/node/45867/psn-pdf
April 12, 2017 - The Economics of Patient Safety: Strengthening a Value-
based Approach to Reducing Patient Harm at National
Level.
April 12, 2017
Slawomirski L, Auraaen A, Klazinga N. Organisation for Economic Co-operation and Development: Paris,
France; 2017.
https://psnet.ahrq.gov/issue/economics-patient-safety-strengthening-v…
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psnet.ahrq.gov/node/47066/psn-pdf
July 11, 2018 - The association between nurse staffing and omissions in
nursing care: a systematic review.
July 11, 2018
Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. The association between nurse staffing and omissions in
nursing care: A systematic review. J Adv Nurs. 2018;74(7):1474-1487. doi:10.1111/jan.13564.
https://psnet…
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psnet.ahrq.gov/node/46825/psn-pdf
June 19, 2018 - Diagnostic performance dashboards: tracking diagnostic
errors using big data.
June 19, 2018
Mane KK, Rubenstein KB, Nassery N, et al. Diagnostic performance dashboards: tracking diagnostic errors
using big data. BMJ Qual Saf. 2018;27(7):567-570. doi:10.1136/bmjqs-2018-007945.
https://psnet.ahrq.gov/issue/diagnosti…
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psnet.ahrq.gov/node/851917/psn-pdf
January 01, 2024 - Incivility in healthcare: the impact of poor
communication.
August 2, 2023
Guppy JH, Widlund H, Munro R, et al. Incivility in healthcare: the impact of poor communication. BMJ Lead.
2024;8(1):83-87. doi:10.1136/leader-2022-000717.
https://psnet.ahrq.gov/issue/incivility-healthcare-impact-poor-communication
Incivi…
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psnet.ahrq.gov/node/61032/psn-pdf
October 14, 2020 - System Governance Towards Improved Patient Safety:
Key Functions, Approaches and Pathways to
Implementation.
October 14, 2020
Auraaen A, Saar K, Klazinga N for the Organisation for Economic Co-operation and Development. OECD
Publishing, Paris, France; 2020. OECD Health Working Papers, No. 120.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/43111/psn-pdf
November 04, 2014 - E-prescribing errors in community pharmacies: exploring
consequences and contributing factors.
November 4, 2014
Odukoya OK, Stone JA, Chui MA. E-prescribing errors in community pharmacies: exploring consequences
and contributing factors. Int J Med Inform. 2014;83(6):427-37. doi:10.1016/j.ijmedinf.2014.02.004.
http…
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psnet.ahrq.gov/node/837064/psn-pdf
May 11, 2022 - Clinic design for safety during the pandemic: safety or
teamwork, can we only pick one?
May 11, 2022
Lim L, Zimring CM, DuBose JR, et al. Clinic design for safety during the pandemic: safety or teamwork, can
we only pick one? HERD. 2022;15(3):28-41. doi:10.1177/19375867221091310.
https://psnet.ahrq.gov/issue/clini…
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psnet.ahrq.gov/node/72753/psn-pdf
February 17, 2021 - Incidence of accidental awareness during general
anaesthesia in obstetrics: a multicentre, prospective
cohort study.
February 17, 2021
Odor PM, Bampoe S, Lucas DN, et al the Pan-London Peri-operative Audit and Research Network (PLAN),
for the DREAMY Investigators Group. Anaesthesia. 2021;76(6):759-776.
https://ps…