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8961. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35022/psn-pdf
      June 22, 2009 - The investigation and analysis of critical incidents and adverse events in healthcare. June 22, 2009 Woloshynowych M, Rogers S, Taylor-Adams S, et al. The investigation and analysis of critical incidents and adverse events in healthcare. Health Technol Assess. 2005;9(19):1-143, iii. https://psnet.ahrq.gov/issue/in…

8962. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40764/psn-pdf
      December 29, 2014 - Wristbands as aids to reduce misidentification: an ethnographically guided task analysis. December 29, 2014 Smith A, Casey K, Wilson J, et al. Wristbands as aids to reduce misidentification: an ethnographically guided task analysis. Int J Qual Health Care. 2011;23(5):590-9. doi:10.1093/intqhc/mzr045. https://psnet…

8963. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40620/psn-pdf
      July 22, 2011 - The role of documents and documentation in communication failure across the perioperative pathway. A literature review. July 22, 2011 Braaf S, Manias E, Riley R. The role of documents and documentation in communication failure across the perioperative pathway. A literature review. Int J Nurs Stud. 2011;48(8):1024-…

8964. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43574/psn-pdf
      October 08, 2014 - The mixed blessings of smart infusion devices and health care IT. October 8, 2014 Nemeth CP, Brown J, Crandall B, et al. The mixed blessings of smart infusion devices and health care IT. Mil Med. 2014;179(8 Suppl):4-10. doi:10.7205/MILMED-D-13-00505. https://psnet.ahrq.gov/issue/mixed-blessings-smart-infusion-devi…

8965. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43661/psn-pdf
      November 05, 2014 - The human factor. November 5, 2014 Langewiesche W. https://psnet.ahrq.gov/issue/human-factor This magazine article provides a breakdown of the failures that contributed to an airplane crash, including how increasing automation in piloting airplanes can diminish human performance, the reluctance to speak up due to…

8966. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41378/psn-pdf
      March 04, 2015 - Clinically missed cancer: how effectively can radiologists use computer-aided detection? March 4, 2015 Nishikawa RM, Schmidt RA, Linver MN, et al. Clinically Missed Cancer: How Effectively Can Radiologists Use Computer-Aided Detection? American Journal of Roentgenology. 2012;198(3). doi:10.2214/ajr.11.6423. https…

8967. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44854/psn-pdf
      March 16, 2016 - Bring back the autopsy. March 16, 2016 Jauhar S. New York Times. March 3, 2016. https://psnet.ahrq.gov/issue/bring-back-autopsy Performance of autopsies, previously considered an essential learning tool for clinicians, has decreased in recent years due to insufficient funding to cover costs and lack of physician e…

8968. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/845075/psn-pdf
      February 22, 2023 - Artificial intelligence, patient safety, and achieving the quintuple aim in anesthesiology. February 22, 2023 Tan JM, Cannesson MP. APSF Newsletter. 2023;38(2):1,3–4,7. https://psnet.ahrq.gov/issue/artificial-intelligence-patient-safety-and-achieving-quintuple-aim-anesthesiology Technological advancement…

8969. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60585/psn-pdf
      June 10, 2020 - Pandemic presents new hurdles, and hope, for people struggling with addiction. June 10, 2020 Feldman N. Kaiser Health News. June 2, 2020. https://psnet.ahrq.gov/issue/pandemic-presents-new-hurdles-and-hope-people-struggling-addiction Physical distancing as a COVID-19 prevention strategy has had a range of unintend…

8970. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47795/psn-pdf
      February 20, 2019 - Three laws for paperlessness. February 20, 2019 Thimbleby H. Three laws for paperlessness. Digit Health. 2019;5:2055207619827722. doi:10.1177/2055207619827722. https://psnet.ahrq.gov/issue/three-laws-paperlessness The digitization of health care data has had some positive effects on patient safety, but it has also…

8971. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33953/psn-pdf
      February 05, 2018 - Evidence-based Recommendations for Best Practices in Weight Loss Surgery.  February 5, 2018 Expert Panel on Weight Loss Surgery, Betsy Lehman Center for Patient Safety and Medical Error Reduction. Obesity Res. 2005;13(2):203-379. https://psnet.ahrq.gov/issue/expert-panel-weight-loss-surgery-betsy-lehman-center-pat…

8972. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38573/psn-pdf
      April 22, 2009 - Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. April 22, 2009 Lippi G, Blanckaert N, Bonini P, et al. Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. Clin Chem Lab Med. 2009;47(2):143-53. doi:10.1515/CCLM.2009.0…

8973. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34904/psn-pdf
      February 27, 2009 - Suboptimal prescribing in elderly outpatients: potentially harmful drug-drug and drug-disease combinations. February 27, 2009 Zhan C, Correa-de-Araujo R, Bierman AS, et al. Suboptimal prescribing in elderly outpatients: potentially harmful drug-drug and drug-disease combinations. J Am Geriatr Soc. 2005;53(2):262-7.…

8974. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46520/psn-pdf
      December 19, 2017 - The emotional fallout from the culture of blame and shame. December 19, 2017 Ferguson CC. The emotional fallout from the culture of blame and shame. JAMA Pediatr. 2017;171(12):1141. doi:10.1001/jamapediatrics.2017.2691. https://psnet.ahrq.gov/issue/emotional-fallout-culture-blame-and-shame In this commentary, a p…

8975. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50734/psn-pdf
      December 11, 2019 - The evolution of patient safety procedures in an oral surgery department December 11, 2019 Graham C, Reid S, Lord TC, et al. The evolution of patient safety procedures in an oral surgery department. Br Dent J. 2019;226(1):32-38. doi:10.1038/sj.bdj.2019.5. https://psnet.ahrq.gov/issue/evolution-patient-safety-proce…

8976. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44998/psn-pdf
      April 20, 2016 - High reliability: excellent care every time. April 20, 2016 Saver C. High reliability: Excellent care every time. OR manager. 2016;32(3):22-6. https://psnet.ahrq.gov/issue/high-reliability-excellent-care-every-time Achieving high reliability has attracted attention as a goal in health care. This article provides an…

8977. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44551/psn-pdf
      September 30, 2015 - Safety culture includes "good catches." September 30, 2015 Traynor K. Safety culture includes "good catches". Am J Health Syst Pharm. 2015;72(19):1597-1599. doi:10.2146/news150065. https://psnet.ahrq.gov/issue/safety-culture-includes-good-catches Near misses can provide opportunities for learning if there is a pro…

8978. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41900/psn-pdf
      December 05, 2012 - Impact of an intervention to reduce prescribing errors in a pediatric intensive care unit. December 5, 2012 Martinez-Anton A, Sanchez I, Casanueva L. Impact of an intervention to reduce prescribing errors in a pediatric intensive care unit. Intensive Care Med. 2012;38(9):1532-8. doi:10.1007/s00134-012-2609-x. http…

8979. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42505/psn-pdf
      August 28, 2013 - Setting quality and safety priorities in a target-rich environment: an academic medical center's challenge. August 28, 2013 Mort E, Demehin AA, Marple KB, et al. Setting quality and safety priorities in a target-rich environment: an academic medical center's challenge. Acad Med. 2013;88(8):1099-104. doi:10.1097/AC…

8980. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43879/psn-pdf
      February 04, 2015 - Complaints and Raising Concerns. February 4, 2015 Fourth Report of Session 2014–15. House of Commons Health Committee. London, England: The Stationery Office; January 13, 2015. Publication HC 350. https://psnet.ahrq.gov/issue/complaints-and-raising-concerns Complaints are a proactive way to monitor and address rec…