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8781. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46687/psn-pdf
      February 21, 2018 - Oversedation of a patient with obstructive sleep apnea prior to imaging. February 21, 2018 Blay E, Barnard C, Bilimoria KY. Oversedation of a Patient With Obstructive Sleep Apnea Prior to Imaging. JAMA. 2018;319(5):495-496. doi:10.1001/jama.2017.22004. https://psnet.ahrq.gov/issue/oversedation-patient-obstructive-…

8782. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46452/psn-pdf
      November 15, 2017 - Quality Improvement. November 15, 2017 Gupta M, Kaplan HC, eds. Clin Perinatol. 2017;44(3):469-728. https://psnet.ahrq.gov/issue/quality-improvement Improvement efforts in health care focus on quality and patient safety. Articles in this special issue explore the complexities of providing effective perinatal–neona…

8783. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39267/psn-pdf
      April 01, 2010 - What have we learned about interventions to reduce medical errors? April 1, 2010 Woodward HI, Mytton OT, Lemer C, et al. What have we learned about interventions to reduce medical errors? Annu Rev Public Health. 2010;31:479-97 1 p following 497. doi:10.1146/annurev.publhealth.012809.103544. https://psnet.ahrq.gov…

8784. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43790/psn-pdf
      October 23, 2023 - Complaints to the Parliamentary and Health Service Ombudsman. October 23, 2023 Manchester, UK: Parliamentary and Health Service Ombudsman. https://psnet.ahrq.gov/issue/complaints-about-acute-trusts-2016-2017 The National Health Service broadly reports the results of system-level analyses and investigations into t…

8785. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45834/psn-pdf
      February 22, 2017 - Implementing an error disclosure coaching model: a multicenter case study. February 22, 2017 White AA, Brock DM, McCotter PI, et al. Implementing an error disclosure coaching model: A multicenter case study. J Healthc Risk Manag. 2017;36(3):34-45. doi:10.1002/jhrm.21260. https://psnet.ahrq.gov/issue/implementing-e…

8786. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39100/psn-pdf
      January 28, 2010 - Hospital governance and the quality of care. January 28, 2010 Jha AK, Epstein AM. Hospital governance and the quality of care. Health Aff (Millwood). 2010;29(1):182-7. doi:10.1377/hlthaff.2009.0297. https://psnet.ahrq.gov/issue/hospital-governance-and-quality-care This study surveyed more than 700 board chairs and…

8787. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39098/psn-pdf
      November 11, 2009 - Building team and technical competency for obstetric emergencies: the mobile obstetric emergencies simulator (MOES) system. November 11, 2009 Deering S, Rosen MA, Salas E, et al. Building team and technical competency for obstetric emergencies: the mobile obstetric emergencies simulator (MOES) system. Simul Health…

8788. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47668/psn-pdf
      January 30, 2019 - Organizing for Reliability: A Guide for Research and Practice. January 30, 2019 Ramanujam R, Roberts KH, eds. Stanford, CA: Stanford University Press; 2018. ISBN: 9780804793612. https://psnet.ahrq.gov/issue/organizing-reliability-guide-research-and-practice High reliability principles guide safety efforts in compl…

8789. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35079/psn-pdf
      November 04, 2015 - Medical Error: What Do We Know? What Do We Do? November 4, 2015 Rosenthal MM; Sutcliffe KM, eds. San Francisco, CA: Jossey-Bass; 2002. https://psnet.ahrq.gov/issue/medical-error-what-do-we-know-what-do-we-do Opening with a review of lessons learned since the Harvard Medical Practice Study (HMPS), this book explore…

8790. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45185/psn-pdf
      August 03, 2016 - Final Report of the Commission on Care. August 3, 2016 Washington, DC: Commission on Care; June 2016. https://psnet.ahrq.gov/issue/final-report-commission-care The Veterans Affairs health system has recently faced challenges associated with access and quality. Providing an assessment of the current and future stat…

8791. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47821/psn-pdf
      May 22, 2019 - Patient Safety. May 22, 2019 National Pharmacy Association; NPA. https://psnet.ahrq.gov/issue/patient-safety-15 This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It i…

8792. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47460/psn-pdf
      October 10, 2018 - A surgeon so bad it was criminal. October 10, 2018 Beil L. ProPublica. October 2, 2018. https://psnet.ahrq.gov/issue/surgeon-so-bad-it-was-criminal This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted…

8793. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42902/psn-pdf
      January 29, 2014 - Improving Patient Safety Through Teamwork and Team Training. January 29, 2014 Salas E, Frush K, eds. Oxford, UK: Oxford University Press; 2013. ISBN: 9780195399097. https://psnet.ahrq.gov/issue/improving-patient-safety-through-teamwork-and-team-training Health care has been recently been directed toward focusing o…

8794. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34753/psn-pdf
      March 28, 2005 - Report on the Medical Insurance Feasibility Study. March 28, 2005 Mills DH. San Francisco, CA: California Medical Association; 1977. https://psnet.ahrq.gov/issue/report-medical-insurance-feasibility-study Escalating professional liability costs prompted this study on the nature of adverse outcomes related to medic…

8795. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35021/psn-pdf
      April 03, 2012 - Health Information Technology Leadership Panel: Final Report. April 3, 2012 Lewin Group: Falls Church, VA; March 2005. https://psnet.ahrq.gov/issue/health-information-technology-leadership-panel-final-report Prepared by the Lewin Group for the Department of Health and Human Services, this 45-page report summarize…

8796. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867773/psn-pdf
      February 01, 2024 - Central Line Insertion Care Team Checklist. February 1, 2024 Agency for Healthcare Research and Quality. Central Line Insertion Care Team Checklist. https://psnet.ahrq.gov/issue/central-line-insertion-care-team-checklist Checklists are helpful in reducing omissions in standardized processes designed to support safe…

8797. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46316/psn-pdf
      August 02, 2017 - Defending a "never event." August 2, 2017 Shepperd JR. Defending a "Never Event". J Healthc Risk Manag. 2017;37(1):17-22. doi:10.1002/jhrm.21277. https://psnet.ahrq.gov/issue/defending-never-event Surgical fires are considered a never event. This commentary provides an overview of surgical fires, explains element…

8798. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47696/psn-pdf
      February 22, 2019 - Operating room fires. February 22, 2019 Jones TS, Black IH, Robinson TN, et al. Operating Room Fires. Anesthesiology. 2019;130(3):492-501. doi:10.1097/ALN.0000000000002598. https://psnet.ahrq.gov/issue/operating-room-fires Surgical fires, though uncommon, can result in serious harm. This review highlights three co…

8799. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46673/psn-pdf
      March 21, 2018 - Human factors and simulation in emergency medicine. March 21, 2018 Hayden EM, Wong AH, Ackerman J, et al. Human Factors and Simulation in Emergency Medicine. Acad Emerg Med. 2018;25(2):221-229. doi:10.1111/acem.13315. https://psnet.ahrq.gov/issue/human-factors-and-simulation-emergency-medicine Human factors engine…

8800. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36506/psn-pdf
      April 19, 2011 - Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems. April 19, 2011 Hearns S, Shirley PJ. Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems. Emerg Med J. 2006;23(12):943-7. https://psnet.ahrq.gov/issue/retri…