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psnet.ahrq.gov/issue/federal-speech-rulings-may-embolden-health-care-workers-call-out-safety-issues
July 24, 2013 - Newspaper/Magazine Article
Federal speech rulings may embolden health care workers to call out safety issues.
Citation Text:
Federal speech rulings may embolden health care workers to call out safety issues. Meyer H. Kaiser Health News. July 9, 2021.
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psnet.ahrq.gov/issue/implementing-aorn-recommended-practices-laser-safety
July 16, 2018 - Commentary
Implementing AORN recommended practices for laser safety.
Citation Text:
Castelluccio D, Nurses A of OR. Implementing AORN Recommended Practices for Laser Safety. AORN J. 2012;95(5):612-24; quiz 625-7. doi:10.1016/j.aorn.2012.03.001.
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psnet.ahrq.gov/issue/focusing-health-care-safety
January 16, 2008 - Special or Theme Issue
Focusing on Health Care Safety.
Citation Text:
Focusing on Health Care Safety. IEEE Transactions on Systems, Man, and Cybernetics, Part A: Systems and Humans. 2004;34(601):689-778.
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psnet.ahrq.gov/issue/studying-organisational-cultures-and-their-effects-safety
April 20, 2014 - Commentary
Studying organisational cultures and their effects on safety.
Citation Text:
Hopkins A. Studying organisational cultures and their effects on safety. Saf Sci. 2006;44(10). doi:10.1016/j.ssci.2006.05.005.
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psnet.ahrq.gov/issue/rudeness-work
May 29, 2014 - Commentary
Rudeness at work.
Citation Text:
Flin R. Rudeness at work. BMJ. 2010;340:c2480. doi:10.1136/bmj.c2480.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/guidelines-practice
March 05, 2010 - Special or Theme Issue
Guidelines in Practice.
Citation Text:
Guidelines in Practice. AORN J. 2020-2024.
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psnet.ahrq.gov/issue/exploring-alternatives-malpractice-litigation
September 01, 2018 - Special or Theme Issue
Exploring Alternatives To Malpractice Litigation.
Citation Text:
Improved safety, eliminating errors top policy agenda. Health Aff (Millwood). 2014;33(1):6-66.
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psnet.ahrq.gov/issue/misidentification-alphanumeric-symbols
March 26, 2014 - Newspaper/Magazine Article
Misidentification of alphanumeric symbols.
Citation Text:
Misidentification of alphanumeric symbols. ISMP Medication Safety Alert! Acute care edition. June 5, 2014;19:1-2,4-5.
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psnet.ahrq.gov/issue/human-contribution-unsafe-acts-accidents-and-heroic-recoveries
August 06, 2016 - Book/Report
Classic
The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries.
Citation Text:
The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Reason J. Farnham Surrey, UK: Ashgate; 2008. ISBN: 9780754674023.
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psnet.ahrq.gov/issue/resilience-engineering-practice-guidebook
February 06, 2019 - Book/Report
Classic
Resilience Engineering in Practice: a Guidebook.
Citation Text:
Resilience Engineering in Practice: a Guidebook. Hollnagel E, Pariès J, Woods DD et al eds. Farnham UK; Ashgate, 2011. ISBN: 9781472420749
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psnet.ahrq.gov/issue/sentinel-event-statistics-1995-2019
February 28, 2018 - Measurement Tool/Indicator
Sentinel Event Data Summary.
Citation Text:
Sentinel Event Data Summary. Joint Commission.
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psnet.ahrq.gov/issue/disclosure-errors-surgical-procedures
April 13, 2022 - Review
Disclosure of errors in surgical procedures.
Citation Text:
Disclosure of errors in surgical procedures. Ryan M, Mekel M, Sinha MS. UptoDate. November 20, 2023.
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psnet.ahrq.gov/issue/inadvertent-administration-oral-liquid-medicine-vein
January 22, 2020 - Book/Report
Inadvertent Administration of an Oral Liquid Medicine into a Vein.
Citation Text:
Inadvertent Administration of an Oral Liquid Medicine into a Vein. Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…
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psnet.ahrq.gov/node/49724/psn-pdf
January 01, 2015 - Bowel Injury After Laparoscopic Surgery
January 1, 2015
Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
The Case
A 30-year-old man presented to the hospital for a scheduled laparoscopic inguinal hernia repair with mes…
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psnet.ahrq.gov/node/49524/psn-pdf
November 01, 2006 - Secured But Not Always Safe
November 1, 2006
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/secured-not-always-safe
The Case
An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative
osteoarthritis. She received spinal …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case April 2006
Is the “Surgical Personality” a Threat to Patient Safety?
Source and Credits
This presentation is based on the April 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - SPOTLIGHT CASE
Difficult Encounters: A CMO and CNO Respond
Citation Text:
Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/issue/sepsis-recognizing-next-event
July 13, 2010 - Commentary
Sepsis: recognizing the next event.
Citation Text:
Kilburn FL, Bailey P, Price D. Sepsis: recognizing the next event. Nursing (Brux). 2013;43(10):14-6. doi:10.1097/01.NURSE.0000434320.25397.53.
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psnet.ahrq.gov/issue/ferraris-formula-one-handovers-and-handovers-surgery-intensive-care
December 23, 2020 - Newspaper/Magazine Article
Ferrari's Formula One handovers and handovers from surgery to intensive care.
Citation Text:
Ferrari's Formula One handovers and handovers from surgery to intensive care. Sower VE; Duffy JA; Kohers G; ASQ; American Society for Quality.
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