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  1. Normal Accidents: Living with High-Risk Technologies. | PSNet

    psnet.ahrq.gov/issue/normal-accidents-living-high-risk-technologies
    March 06, 2005 - Book/Report Classic Normal Accidents: Living with High-Risk Technologies. Citation Text: Normal Accidents: Living with High-Risk Technologies. Perrow C. Princeton NJ: Princeton University Press; 1999. Copy Citation Save Save to you…

  2. The problem with making Safety-II work in healthcare. | PSNet

    psnet.ahrq.gov/issue/problem-making-safety-ii-work-healthcare
    April 28, 2021 - Commentary The problem with making Safety-II work in healthcare. Citation Text: Verhagen MJ, de Vos MS, Sujan M, et al. The problem with making Safety-II work in healthcare. BMJ Qual Saf. 2022;31(5):402-408. doi:10.1136/bmjqs-2021-014396. Copy Citation Format: DOI Google Sc…

  3. Anesthetic mishaps: breaking the chain of accident evolution. | PSNet

    psnet.ahrq.gov/issue/anesthetic-mishaps-breaking-chain-accident-evolution
    April 08, 2011 - Commentary Classic Anesthetic mishaps: breaking the chain of accident evolution. Citation Text: Gaba DM, Maxwell M, DeAnda A. Anesthetic mishaps: breaking the chain of accident evolution. Anesthesiology. 1987;66(5):670-6. Copy Citation Format: Goo…

  4. Revisiting duty-hour limits — IOM recommendations for patient safety and resident education. | PSNet

    psnet.ahrq.gov/issue/revisiting-duty-hour-limits-iom-recommendations-patient-safety-and-resident-education
    February 17, 2011 - Commentary Revisiting duty-hour limits — IOM recommendations for patient safety and resident education. Citation Text: Iglehart JK. Revisiting duty-hour limits--IOM recommendations for patient safety and resident education. N Engl J Med. 2008;359(25):2633-5. doi:10.1056/NEJMp0808736. …

  5. Morbidity and mortality conference in emergency medicine residencies and the culture of safety. | PSNet

    psnet.ahrq.gov/issue/morbidity-and-mortality-conference-emergency-medicine-residencies-and-culture-safety
    November 16, 2022 - Study Morbidity and mortality conference in emergency medicine residencies and the culture of safety. Citation Text: Aaronson E, Wittels KA, Nadel ES, et al. Morbidity and Mortality Conference in Emergency Medicine Residencies and the Culture of Safety. West J Emerg Med. 2015;16(6):810-7…

  6. The Joint Commission's new and revised workplace violence prevention standards for hospitals: a major step forward toward improved quality and safety. | PSNet

    psnet.ahrq.gov/issue/joint-commissions-new-and-revised-workplace-violence-prevention-standards-hospitals-major
    April 27, 2022 - Commentary The Joint Commission's new and revised workplace violence prevention standards for hospitals: a major step forward toward improved quality and safety. Citation Text: Arnetz JE. The Joint Commission's new and revised workplace violence prevention standards for hospitals: a majo…

  7. Medication safety systems and the important role of pharmacists. | PSNet

    psnet.ahrq.gov/issue/medication-safety-systems-and-important-role-pharmacists
    July 19, 2023 - Review Medication safety systems and the important role of pharmacists. Citation Text: Mansur JM. Medication Safety Systems and the Important Role of Pharmacists. Drugs Aging. 2016;33(3):213-21. doi:10.1007/s40266-016-0358-1. Copy Citation Format: DOI Google Scholar PubMed …

  8. Adaptation and implementation of the WHO Safe Childbirth Checklist around the world. | PSNet

    psnet.ahrq.gov/issue/adaptation-and-implementation-who-safe-childbirth-checklist-around-world
    March 17, 2021 - Study Adaptation and implementation of the WHO Safe Childbirth Checklist around the world. Citation Text: Molina RL, Benski A-C, Bobanski L, et al. Adaptation and implementation of the WHO Safe Childbirth Checklist around the world. Implement Sci Commun. 2021;2(1):76. doi:10.1186/s43058-…

  9. A safety evaluation of the impact of maternity-orientated human factors training on safety culture in a tertiary maternity unit. | PSNet

    psnet.ahrq.gov/issue/safety-evaluation-impact-maternity-orientated-human-factors-training-safety-culture-tertiary
    October 19, 2022 - Study A safety evaluation of the impact of maternity-orientated human factors training on safety culture in a tertiary maternity unit. Citation Text: Ansari SP, Rayfield ME, Wallis VA, et al. A Safety Evaluation of the Impact of Maternity-Orientated Human Factors Training on Safety Cultu…

  10. Impact of system-level activities and reporting design on the number of incident reports for patient safety. | PSNet

    psnet.ahrq.gov/issue/impact-system-level-activities-and-reporting-design-number-incident-reports-patient-safety
    January 20, 2011 - Study Impact of system-level activities and reporting design on the number of incident reports for patient safety. Citation Text: Fukuda H, Imanaka Y, Hirose M, et al. Impact of system-level activities and reporting design on the number of incident reports for patient safety. Qual Saf …

  11. Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in general surgery. | PSNet

    psnet.ahrq.gov/issue/continuous-monitoring-adverse-events-influence-quality-care-and-incidence-errors-general
    March 09, 2022 - Study Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in general surgery. Citation Text: Rebasa P, Mora L, Luna A, et al. Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in gener…

  12. The end of the beginning: patient safety five years after 'To Err Is Human.' | PSNet

    psnet.ahrq.gov/issue/end-beginning-patient-safety-five-years-after-err-human
    March 02, 2011 - Commentary Classic The end of the beginning: patient safety five years after 'To Err Is Human.' Citation Text: Wachter RM. The End Of The Beginning: Patient Safety Five Years After ‘To Err Is Human’. Health Aff. 2004;23(Suppl1). doi:10.1377/hlthaff.w4.534. C…

  13. The Next Generation of RHIOs: Health Information Exchange Through Common Shared Record (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/2006Cauley_051311comp.pdf
    June 16, 2021 - The Next Generation of RHIOs: Health Information Exchange Through Common Shared Record The Next Generation of RHIOs: Health Information Exchange Through Common Shared Record Presented by Kate Cauley, PhD, Director Center for Healthy Communities Boonshoft School of Medicine Wright State University, Dayton, Ohio…

  14. Changes in physician practice patterns after implementation of a communication-and-resolution program. | PSNet

    psnet.ahrq.gov/issue/changes-physician-practice-patterns-after-implementation-communication-and-resolution-program
    September 01, 2018 - Study Changes in physician practice patterns after implementation of a communication-and-resolution program. Citation Text: Helmchen LA, Lambert BL, McDonald TB. Changes in Physician Practice Patterns after Implementation of a Communication-and-Resolution Program. Health Serv Res. 2016;5…

  15. Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effectiveness. | PSNet

    psnet.ahrq.gov/issue/bridging-gap-leveraging-business-intelligence-tools-support-patient-safety-and-financial
    February 15, 2011 - Commentary Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effectiveness. Citation Text: Ferranti JM, Langman MK, Tanaka D, et al. Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effe…

  16. Interprofessional education in team communication: working together to improve patient safety. | PSNet

    psnet.ahrq.gov/issue/interprofessional-education-team-communication-working-together-improve-patient-safety
    April 24, 2018 - Study Interprofessional education in team communication: working together to improve patient safety. Citation Text: Brock DM, Abu-Rish E, Chiu C-R, et al. Interprofessional education in team communication: working together to improve patient safety. BMJ Qual Saf. 2013;22(5):414-23. doi…

  17. SBAR: electronic handoff tool for noncomplicated procedural patients. | PSNet

    psnet.ahrq.gov/issue/sbar-electronic-handoff-tool-noncomplicated-procedural-patients
    October 19, 2022 - Study SBAR: electronic handoff tool for noncomplicated procedural patients. Citation Text: Wentworth L, Diggins J, Bartel D, et al. SBAR: electronic handoff tool for noncomplicated procedural patients. J Nurs Care Qual. 2012;27(2):125-31. doi:10.1097/NCQ.0b013e31823cc9a0. Copy Citati…

  18. Risk management: extreme honesty may be the best policy. | PSNet

    psnet.ahrq.gov/issue/risk-management-extreme-honesty-may-be-best-policy
    January 04, 2017 - Study Classic Risk management: extreme honesty may be the best policy. Citation Text: Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131(12):963-967. Copy Citation Format: Google Scholar PubMed Bi…

  19. Dealing with unforeseen complexity in the OR: the role of heedful interrelating in medical teams. | PSNet

    psnet.ahrq.gov/issue/dealing-unforeseen-complexity-or-role-heedful-interrelating-medical-teams
    July 06, 2011 - Study Dealing with unforeseen complexity in the OR: the role of heedful interrelating in medical teams. Citation Text: Schraagen JM. Dealing with unforeseen complexity in the OR: the role of heedful interrelating in medical teams. Theor Issues Ergon Sci. 2011;12(3). doi:10.1080/1464536…

  20. A patient safety curriculum for medical residents based on the perspectives of residents and supervisors. | PSNet

    psnet.ahrq.gov/issue/patient-safety-curriculum-medical-residents-based-perspectives-residents-and-supervisors
    April 14, 2011 - Study A patient safety curriculum for medical residents based on the perspectives of residents and supervisors. Citation Text: Jansma JD, Wagner C, Bijnen AB. A patient safety curriculum for medical residents based on the perspectives of residents and supervisors. J Patient Saf. 2011;7…
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