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9041. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60875/psn-pdf
      September 02, 2020 - Understanding context specificity: the effect of contextual factors on clinical reasoning. September 2, 2020 Konopasky A, Artino AR, Battista A, et al. Understanding context specificity: the effect of contextual factors on clinical reasoning. Diagnosis (Berl). 2020;79(3):257-264. doi:10.1515/dx-2020-0016. https://…

9042. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46422/psn-pdf
      November 29, 2017 - Framework for direct observation of performance and safety in healthcare. November 29, 2017 Catchpole K, Neyens DM, Abernathy J, et al. Framework for direct observation of performance and safety in healthcare. BMJ Qual Saf. 2017;26(12):1015-1021. doi:10.1136/bmjqs-2016-006407. https://psnet.ahrq.gov/issue/framewor…

9043. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39274/psn-pdf
      November 23, 2016 - Keeping an eye on patient safety using human factors engineering (HFE): a family affair for the hospitalized child. November 23, 2016 Wilson BL. Keeping an eye on patient safety using human factors engineering (HFE): a family affair for the hospitalized child. J Spec Pediatr Nurs. 2010;15(1):84-7. doi:10.1111/j.17…

9044. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45906/psn-pdf
      June 22, 2017 - A piece of my mind. After the medical error. June 22, 2017 Worthen M. After the Medical Error. JAMA. 2017;317(17):1763-1764. doi:10.1001/jama.2017.0004. https://psnet.ahrq.gov/issue/piece-my-mind-after-medical-error Patients who have been exposed to medical error could be reluctant to trust the health care system. …

9045. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46927/psn-pdf
      April 04, 2018 - Clinician Well-Being Knowledge Hub. April 4, 2018 Washington, DC: National Academy of Medicine. https://psnet.ahrq.gov/issue/clinician-well-being-knowledge-hub Clinician burnout can detract from individual wellness, patient safety, and organizational health. This website serves as a companion to a collaborative ef…

9046. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39227/psn-pdf
      January 13, 2010 - Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery. January 13, 2010 Erickson TB, Kirkpatrick DH, DeFrancesco MS, et al. Executive summary of the American College of …

9047. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46438/psn-pdf
      September 20, 2017 - Communicating Clearly About Medicines: Proceedings of a Workshop. September 20, 2017 National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press: 2017. ISBN: 9780309461856. https://psnet.ahrq.gov/issue/communicating-clearly-about-medicines-proceedings-workshop Patient h…

9048. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836835/psn-pdf
      March 30, 2022 - Bias in mental health diagnosis gets in the way of treatment. March 30, 2022 Garb HN. Psyche. March 22, 2022. https://psnet.ahrq.gov/issue/bias-mental-health-diagnosis-gets-way-treatment A wide array of biases can affect clinical judgement and contribute to diagnostic error. This article discusses the impact of i…

9049. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36838/psn-pdf
      April 19, 2011 - A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. April 19, 2011 Walshe K, Offen N. A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. Qual Health Care. 2001;10(4):250-6. https://psn…

9050. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61003/psn-pdf
      October 07, 2020 - Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments. October 7, 2020 Manchester, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN 9781528620666. https://psnet.ahrq.gov/issue/making-complaints-count-supporting-complaints-handling-nhs-and-uk- gover…

9051. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40205/psn-pdf
      April 14, 2011 - Patient safety in out-of-hours primary care: a review of patient records. April 14, 2011 Smits M, Huibers L, Kerssemeijer B, et al. Patient safety in out-of-hours primary care: a review of patient records. BMC Health Serv Res. 2010;10:335. doi:10.1186/1472-6963-10-335. https://psnet.ahrq.gov/issue/patient-safety-o…

9052. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41105/psn-pdf
      December 16, 2013 - Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies. December 16, 2013 Davis R, Sevdalis N, Pinto A, et al. Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies. Health Expect. 2013;16(4):e164-76. doi:10.1…

9053. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42872/psn-pdf
      December 30, 2014 - Errors in after-hours phone consultations: a simulation study. December 30, 2014 Joffe E, Turley JP, Hwang KO, et al. Errors in after-hours phone consultations: a simulation study. BMJ Qual Saf. 2014;23(5):398-405. doi:10.1136/bmjqs-2013-002243. https://psnet.ahrq.gov/issue/errors-after-hours-phone-consultations-s…

9054. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42625/psn-pdf
      November 08, 2013 - Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items. November 8, 2013 Judson TJ, Howell MD, Guglielmi C, et al. Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items. Jt Comm J Qual Patient Saf. 2013;39(10):4…

9055. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47067/psn-pdf
      May 16, 2018 - Senior staff safety rounds: a commitment to ensure safety is the top priority. May 16, 2018 O'Connell RT, Ivy ME. NEJM Catalyst. May 1, 2018. https://psnet.ahrq.gov/issue/senior-staff-safety-rounds-commitment-ensure-safety-top-priority Leadership participation at the front lines can drive safety improvement work. …

9056. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44955/psn-pdf
      May 21, 2016 - Accuracy of the Safer Dx Instrument to identify diagnostic errors in primary care. May 21, 2016 Al-Mutairi A, Meyer AND, Thomas EJ, et al. Accuracy of the Safer Dx Instrument to Identify Diagnostic Errors in Primary Care. J Gen Intern Care. 2016;31(6):602-608. doi:10.1007/s11606-016-3601-x. https://psnet.ahrq.gov/…

9057. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45025/psn-pdf
      May 04, 2016 - Reducing prognostic errors: a new imperative in quality healthcare. May 4, 2016 Khullar D, Jena AB. Reducing prognostic errors: a new imperative in quality healthcare. BMJ. 2016;352:i1417. doi:10.1136/bmj.i1417. https://psnet.ahrq.gov/issue/reducing-prognostic-errors-new-imperative-quality-healthcare This comment…

9058. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46451/psn-pdf
      September 27, 2017 - Health Care Facility Design Safety Risk Assessment Toolkit. September 27, 2017 Rockville, MD: Agency for Healthcare Research and Quality; 2017. https://psnet.ahrq.gov/issue/health-care-facility-design-safety-risk-assessment-toolkit Both organizational culture and the physical environment affect the safety of care …

9059. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43994/psn-pdf
      August 02, 2015 - Using simulation to improve patient safety: dawn of a new era. August 2, 2015 Cheng A, Grant V, Auerbach M. Using simulation to improve patient safety: dawn of a new era. JAMA Pediatr. 2015;169(5):419-20. doi:10.1001/jamapediatrics.2014.3817. https://psnet.ahrq.gov/issue/using-simulation-improve-patient-safety-daw…

9060. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39062/psn-pdf
      November 11, 2009 - Ensuring patient safety through effective leadership behaviour: a literature review. November 11, 2009 Künzle B, Kolbe M, Grote G. Ensuring patient safety through effective leadership behaviour: A literature review. Saf Sci. 2009;48(1). doi:10.1016/j.ssci.2009.06.004. https://psnet.ahrq.gov/issue/ensuring-patient-…