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8821. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34757/psn-pdf
      November 18, 2015 - Unity of Mistakes: A Phenomenological Interpretation of Medical Work. November 18, 2015 Paget MA. Philadelphia: Temple University Press; 2004. https://psnet.ahrq.gov/issue/unity-mistakes-phenomenological-interpretation-medical-work In this often described landmark text on the nature of medical error, Marianne Page…

8822. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45006/psn-pdf
      April 06, 2016 - Quality and Patient Safety. April 6, 2016 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/quality-and-patient-safety The Agency for Healthcare Research and Quality has provided access to patient safety research, information, and tools for nearly two decades. This website offers a wide rang…

8823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44016/psn-pdf
      November 21, 2016 - Partnering to Improve Quality and Safety: A Framework for Working With Patient and Family Advisors. November 21, 2016 Chicago, IL: Health Research & Educational Trust; 2015. https://psnet.ahrq.gov/issue/partnering-improve-quality-and-safety-framework-working-patient-and-family- advisors Patient and family advisor…

8824. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45995/psn-pdf
      May 24, 2017 - Patient Safety. May 24, 2017 Todd DW, Bennett JD, eds. Oral Maxillofac Surg Clin North Am. 2017;29:121-244. https://psnet.ahrq.gov/issue/patient-safety-13 Articles in this special issue provide insights into how human error can affect the safety of oral and maxillofacial surgery, a primarily ambulatory environment…

8825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44091/psn-pdf
      January 04, 2019 - Isolation precautions for visitors. January 4, 2019 Munoz-Price LS, Banach DB, Bearman G, et al. Isolation Precautions for Visitors. Infect Control Hosp Epidemiol. 2015;36(7):747-758. doi:10.1017/ice.2015.67. https://psnet.ahrq.gov/issue/isolation-precautions-visitors This expert guidance provides recommendations …

8826. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43376/psn-pdf
      January 16, 2017 - Resilience and resilience engineering in health care. January 16, 2017 Fairbanks RJ, Wears RL, Woods DD, et al. Resilience and resilience engineering in health care. Jt Comm J Qual Patient Saf. 2014;40(8):376-383. https://psnet.ahrq.gov/issue/resilience-and-resilience-engineering-health-care Resilience is a charac…

8827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60587/psn-pdf
      June 10, 2020 - Person-Centered Guidelines for Preserving Family Presence in Challenging Times. June 10, 2020 Derby, CT: Planetree; 2020. https://psnet.ahrq.gov/issue/person-centered-guidelines-preserving-family-presence-challenging-times Families have an important role in keeping patients safe. This book provides a set of patien…

8828. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37793/psn-pdf
      February 15, 2011 - Educating seniors to be patient safety self-advocates in primary care. February 15, 2011 Elder NC, Regan SL, Pallerla H, et al. Educating Seniors to Be Patient Safety Self-Advocates in Primary Care. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e318175d806. https://psnet.ahrq.gov/issue/educating-seniors-be-patien…

8829. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41222/psn-pdf
      May 01, 2016 - Reducing Unnecessary Hospital Readmissions: The Role of the Patient Safety Organization (PSO). May 1, 2016 Agency for Healthcare Quality and Research. https://psnet.ahrq.gov/issue/reducing-unnecessary-hospital-readmissions-role-patient-safety-organization- pso Patient safety organizations (PSO) present a unique o…

8830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34788/psn-pdf
      March 28, 2005 - Cost of medication-related problems at a university hospital. March 28, 2005 Schneider PJ; Gift MG; Lee YP; Rothermich EA; Sill BE https://psnet.ahrq.gov/issue/cost-medication-related-problems-university-hospital This study used retrospective chart review to determine estimated costs of defined medication-related …

8831. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35193/psn-pdf
      July 10, 2008 - Diagnostic error in internal medicine. July 10, 2008 Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499. https://psnet.ahrq.gov/issue/diagnostic-error-internal-medicine This study identified 100 cases of diagnostic error in internal medicine and conducte…

8832. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34036/psn-pdf
      March 28, 2005 - National Center for Patient Safety Falls Toolkit 2004. March 28, 2005 Department of Veterans Affairs (VA) National Center for Patient Safety https://psnet.ahrq.gov/issue/national-center-patient-safety-falls-toolkit-2004 The National Center for Patient Safety created the Falls Toolkit to assist VA facilities in impl…

8833. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39486/psn-pdf
      May 05, 2010 - Understanding handling of drug safety alerts: a simulation study. May 5, 2010 van der Sijs H, van Gelder T, Vulto A, et al. Understanding handling of drug safety alerts: a simulation study. Int J Med Inform. 2010;79(5). doi:10.1016/j.ijmedinf.2010.01.008. https://psnet.ahrq.gov/issue/understanding-handling-drug-sa…

8834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41081/psn-pdf
      February 01, 2012 - Workarounds in the use of IS in healthcare: a case study of an electronic medication administration system. February 1, 2012 Yang Z, Ng B-Y, Kankanhalli A, et al. Workarounds in the use of IS in healthcare: A case study of an electronic medication administration system. International Journal of Human-Computer Studi…

8835. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35564/psn-pdf
      June 17, 2014 - Medication safety issue brief. Small and rural hospitals—unique challenges, unique solutions. June 17, 2014 Association AH, Pharmacists AS of H-S, Networks H & H. Medication Safety Issue Brief. Small and rural hospitals--unique challenges, unique solutions. Hospitals & health networks. 2005;79(11):45-6. https://ps…

8836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43509/psn-pdf
      September 10, 2014 - Patient Safety in Private Hospitals: the Known and the Unknown Risk. September 10, 2014 Leys C, Toft B. London, UK: Centre for Health and the Public Interest; August 2014. https://psnet.ahrq.gov/issue/patient-safety-private-hospitals-known-and-unknown-risk This report discusses issues with staffing, equipment, and…

8837. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36110/psn-pdf
      April 04, 2024 - Sentinel Event Data Summary. April 4, 2024 Joint Commission. https://psnet.ahrq.gov/issue/sentinel-event-statistics-1995-2019 This website provides sentinel event data reported to The Joint Commission, which includes information on sentinel events reported from January through December 2023. Falls, wrong surgery a…

8838. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44873/psn-pdf
      March 21, 2016 - Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. March 21, 2016 Cambridge, MA: CRICO Strategies; 2016. https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report Communication failures are known to contribute to medical errors. Analyzing more …

8839. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50595/psn-pdf
      January 01, 2020 - Clinical reasoning as a core competency. October 30, 2019 Connor DM, Durning SJ, Rencic J. Clinical Reasoning as a Core Competency. Acad Med. 2020;95(8):1166-1171. doi:10.1097/acm.0000000000003027. https://psnet.ahrq.gov/issue/clinical-reasoning-core-competency Enhancing clinical reasoning skill, particularly amon…

8840. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/842778/psn-pdf
      January 18, 2023 - During in-flight emergencies, sometimes airlines’ medical kits fall short. January 18, 2023 Ramachandran V. Kaiser Health News. January 6, 2023. https://psnet.ahrq.gov/issue/during-flight-emergencies-sometimes-airlines-medical-kits-fall-short Inadequate equipment and personnel training degrade the reliability of i…