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psnet.ahrq.gov/node/838193/psn-pdf
September 28, 2022 - Economics of Medication Safety. Improving Medication
Safety Through Collective, Real-time Learning.
September 28, 2022
de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and
Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.
…
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psnet.ahrq.gov/node/43981/psn-pdf
April 22, 2015 - National Aeronautics and Space Administration "threat
and error" model applied to pediatric cardiac surgery:
error cycles precede ?85% of patient deaths.
April 22, 2015
Hickey EJ, Nosikova Y, Pham-Hung E, et al. National Aeronautics and Space Administration "threat and
error" model applied to pediatric cardiac sur…
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psnet.ahrq.gov/node/837961/psn-pdf
August 31, 2022 - Risk reduction strategy to decrease incidence of retained
surgical items.
August 31, 2022
Kaplan HJ, Spiera ZC, Feldman DL, et al. Risk reduction strategy to decrease incidence of retained
surgical items. J Am Coll Surg. 2022;235(3):494-499. doi:10.1097/xcs.0000000000000264.
https://psnet.ahrq.gov/issue/risk-reduc…
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psnet.ahrq.gov/node/61058/psn-pdf
October 28, 2020 - Interventions and measurements of highly
reliable/resilient organization implementations: a
literature review.
October 28, 2020
Cantu J, Tolk J, Fritts S, et al. Interventions and measurements of highly reliable/resilient organization
implementations: a literature review. Appl Ergon. 2020;90:103241. doi:10.1016/j.…
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psnet.ahrq.gov/node/47453/psn-pdf
May 20, 2019 - Patient safety and the ageing physician: a qualitative
study of key stakeholder attitudes and experiences.
May 20, 2019
White AA, Sage WM, Osinska PH, et al. Patient safety and the ageing physician: a qualitative study of key
stakeholder attitudes and experiences. BMJ Qual Saf. 2019;28(6):468-475. doi:10.1136/bmjqs…
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psnet.ahrq.gov/node/43992/psn-pdf
April 25, 2016 - Collaborating—or "selling" patients? A conceptual
framework for emergency department-to-inpatient handoff
negotiations.
April 25, 2016
Hilligoss B, Mansfield JA, Patterson ES, et al. Collaborating-or "Selling" Patients? A Conceptual Framework
for Emergency Department-to-Inpatient Handoff Negotiations. Jt Comm J Qu…
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psnet.ahrq.gov/node/35762/psn-pdf
January 02, 2017 - Using Failure Mode and Effects Analysis for safe
administration of chemotherapy to hospitalized children
with cancer.
January 2, 2017
Robinson DL, Heigham M, Clark J. Using Failure Mode and Effects Analysis for safe administration of
chemotherapy to hospitalized children with cancer. Jt Comm J Qual Patient Saf. 20…
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psnet.ahrq.gov/node/43954/psn-pdf
May 13, 2015 - Training safer surgeons: how do patients view the role of
simulation in orthopaedic training?
May 13, 2015
Akhtar K, Sugand K, Wijendra A, et al. Training safer surgeons: How do patients view the role of simulation
in orthopaedic training? Patient Saf Surg. 2015;9:11. doi:10.1186/s13037-015-0058-5.
https://psnet.a…
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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - August 21, 2015
WebM&M Cases
Good Catch in the Operating
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psnet.ahrq.gov/node/837758/psn-pdf
August 03, 2022 - Association of anesthesiologist staffing ratio with
surgical patient morbidity and mortality.
August 3, 2022
Burns ML, Saager L, Cassidy RB, et al. Association of anesthesiologist staffing ratio with surgical patient
morbidity and mortality. JAMA Surg. 2022;157(9):807-815. doi:10.1001/jamasurg.2022.2804.
https://p…
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psnet.ahrq.gov/node/45459/psn-pdf
January 03, 2017 - Applying the high reliability health care maturity model to
assess hospital performance: a VA case study.
January 3, 2017
Sullivan JL, Rivard PE, Shin MH, et al. Applying the High Reliability Health Care Maturity Model to Assess
Hospital Performance: A VA Case Study. Jt Comm J Qual Patient Saf. 2016;42(9):389-411.
…
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psnet.ahrq.gov/node/46572/psn-pdf
January 01, 2018 - Effects of efforts to optimise morbidity and mortality
rounds to serve contemporary quality improvement and
educational goals: a systematic review.
December 21, 2017
Smaggus A, Mrkobrada M, Marson A, et al. Effects of efforts to optimise morbidity and mortality rounds to
serve contemporary quality improvement and …
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psnet.ahrq.gov/node/840478/psn-pdf
November 30, 2022 - Interventions into reliability-seeking health care
organizations: a systematic review of their goals and
measuring methods.
November 30, 2022
Auschra C, Asaad E, Sydow J, et al. Interventions into reliability-seeking health care organizations: a
systematic review of their goals and measuring methods. J Patient Saf…
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psnet.ahrq.gov/node/47331/psn-pdf
October 17, 2018 - Description and factors associated with missed nursing
care in an acute care community hospital.
October 17, 2018
Duffy JR, Culp S, Padrutt T. Description and factors associated with missed nursing care in an acute care
community hospital. J Nurs Adm. 2018;48(7-8):361-367. doi:10.1097/NNA.0000000000000630.
https:/…
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psnet.ahrq.gov/node/856591/psn-pdf
November 29, 2023 - Relationship of the nursing practice environment with the
quality of care and patients' safety in primary health care.
November 29, 2023
Lucas P, Jesus É, Almeida S, et al. Relationship of the nursing practice environment with the quality of care
and patients’ safety in primary health care. BMC Nurs. 2023;22(1):413…
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psnet.ahrq.gov/node/45978/psn-pdf
May 03, 2017 - Nursing interruptions in a trauma intensive care unit: a
prospective observational study.
May 3, 2017
Craker NC, Myers RA, Eid J, et al. Nursing Interruptions in a Trauma Intensive Care Unit: A Prospective
Observational Study. J Nurs Adm. 2017;47(4):205-211. doi:10.1097/NNA.0000000000000466.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/40279/psn-pdf
May 25, 2011 - Inadequate health literacy among paid caregivers of
seniors.
May 25, 2011
Lindquist LA, Jain N, Tam K, et al. Inadequate health literacy among paid caregivers of seniors. J Gen
Intern Med. 2011;26(5):474-9. doi:10.1007/s11606-010-1596-2.
https://psnet.ahrq.gov/issue/inadequate-health-literacy-among-paid-caregivers…
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psnet.ahrq.gov/node/865479/psn-pdf
April 03, 2024 - Characteristics and contributing factors of diagnostic
error in surgery: analysis of closed medico-legal cases
and complaints in Canada.
April 3, 2024
Kwan JL, Calder LA, Bowman CL, et al. Characteristics and contributing factors of diagnostic error in
surgery: analysis of closed medico-legal cases and complaints …
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psnet.ahrq.gov/node/34957/psn-pdf
February 28, 2011 - Coordinating care across diseases, settings, and
clinicians: a key role for the generalist in practice.
February 28, 2011
Stille CJ, Jerant A, Bell D, et al. Coordinating care across diseases, settings, and clinicians: a key role for
the generalist in practice. Ann Intern Med. 2005;142(8):700-708.
https://psnet.ah…
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psnet.ahrq.gov/node/72683/psn-pdf
January 27, 2021 - Analysis of patient safety risk management call data
during the COVID?19 pandemic.
January 27, 2021
Wessels R, McCorkle LM. Analysis of patient safety risk management call data during the COVID?19
pandemic. J Healthc Risk Manag. 2021;40(4):30-37. doi:10.1002/jhrm.21457.
https://psnet.ahrq.gov/issue/analysis-patien…