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9381. 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…

9382. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43219/psn-pdf
      January 01, 2015 - Developing a reporting and tracking tool for nursing student errors and near misses. May 28, 2014 Disch J, Barnsteiner J. Developing a Reporting and Tracking Tool for Nursing Student Errors and Near Misses. J Nurs Reg. 2015;5(1):4-10. doi:10.1016/s2155-8256(15)30093-4. https://psnet.ahrq.gov/issue/developing-repor…

9383. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865598/psn-pdf
      April 17, 2024 - Guardians of grafts: reducing medication errors in transplant recipients. April 17, 2024 ISMP Medication Safety Alert! Acute care. April 4, 2024;29(7):1-4. https://psnet.ahrq.gov/issue/guardians-grafts-reducing-medication-errors-transplant-recipients Safe medication therapy for transplant patients is complex and h…

9384. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73450/psn-pdf
      June 30, 2021 - Decision Making in Emergency Medicine: Biases, Errors and Solutions. June 30, 2021 Raz M, Pouryahya P, eds. Singapore; Springer Nature Singapore Pte Ltd; 2021. ISBN 9789811601422. https://psnet.ahrq.gov/issue/decision-making-emergency-medicine-biases-errors-and-solutions Decision making is vulnerable to huma…

9385. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46963/psn-pdf
      April 18, 2018 - A Just Culture Guide. April 18, 2018 NHS Improvement. London, UK: National Health Service; March 15, 2018. https://psnet.ahrq.gov/issue/just-culture-guide Although focusing on system failure has been highlighted as key to improving patient safety, individual behaviors must also be recognized as contributors to ris…

9386. 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://…

9387. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72585/psn-pdf
      December 16, 2020 - Think health care workers are tested often for the Coronavirus? Think again. December 16, 2020 Wamsley L. National Public Radio and WBUR. December 7, 2020. https://psnet.ahrq.gov/issue/think-health-care-workers-are-tested-often-coronavirus-think-again Testing for COVID-19 is a core public safety strategy for …

9388. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47960/psn-pdf
      May 15, 2019 - A systematic review of clinical decision support systems for clinical oncology practice. May 15, 2019 Pawloski PA, Brooks GA, Nielsen ME, et al. A Systematic Review of Clinical Decision Support Systems for Clinical Oncology Practice. J Natl Compr Canc Netw. 2019;17(4):331-338. doi:10.6004/jnccn.2018.7104. https://…

9389. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46790/psn-pdf
      March 14, 2018 - When clinicians drop out and start over after adverse events. March 14, 2018 Rodriquez J, Scott SD. When Clinicians Drop Out and Start Over after Adverse Events. Jt Comm J Qual Patient Saf. 2018;44(3):137-145. doi:10.1016/j.jcjq.2017.08.008. https://psnet.ahrq.gov/issue/when-clinicians-drop-out-and-start-over-afte…

9390. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844551/psn-pdf
      February 15, 2023 - Emotional safety is patient safety. February 15, 2023 Lyndon A, Davis D-A, Sharma AE, et al. Emotional safety is patient safety. BMJ Qual Saf. 2023;32(7):369- 372. doi:10.1136/bmjqs-2022-015573. https://psnet.ahrq.gov/issue/emotional-safety-patient-safety Patient perspectives can provide unique insights into care …

9391. 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-…

9392. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46326/psn-pdf
      October 18, 2017 - Surgical Patient Safety: A Case-Based Approach. October 18, 2017 Stahel PF, ed. New York, NY: McGraw-Hill Education/Medical; 2017. ISBN: 9780071842631. https://psnet.ahrq.gov/issue/surgical-patient-safety-case-based-approach Surgical residency can be a stressful learning experience. This textbook provides an introd…

9393. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866326/psn-pdf
      July 17, 2024 - Telehealth safety framework: addressing a new frontier in patient safety. July 17, 2024 Gomes KM, Apathy N, Krevat SA, et al. Telehealth safety framework: addressing a new frontier in patient safety. J Patient Saf. 2024;20(5):358-359. doi:10.1097/pts.0000000000001243. https://psnet.ahrq.gov/issue/telehealth-safety…

9394. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866524/psn-pdf
      August 14, 2024 - Generative artificial intelligence, patient safety and healthcare quality: a review. August 14, 2024 Howell MD. Generative artificial intelligence, patient safety and healthcare quality: a review. BMJ Qual Saf. 2024;33(11):748-754. doi:10.1136/bmjqs-2023-016690. https://psnet.ahrq.gov/issue/generative-artificial-i…

9395. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851924/psn-pdf
      August 02, 2023 - The things we carry: the scope and impact of second victim syndrome. August 2, 2023 Nosanov L, Elseth AJ, Maxwell J, et al. The things we carry: the scope and impact of second victim syndrome. Am J Surg. 2023;226(5):726-728. doi:10.1016/j.amjsurg.2023.06.035. https://psnet.ahrq.gov/issue/things-we-carry-scope-and-…

9396. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/855105/psn-pdf
      January 01, 2024 - Sentinel Event Alert 68: updated surgical fire prevention for the 21st Century. November 8, 2023 Sentinel Event Alert 68: Updated Surgical Fire Prevention for the 21st Century. Jt Comm J Qual Patient Saf. 2024;50(2):157-160. doi:10.1016/j.jcjq.2023.10.003. https://psnet.ahrq.gov/issue/sentinel-event-alert-68-updat…

9397. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73245/psn-pdf
      May 12, 2021 - Just culture: the foundation of staff safety in the perioperative environment. May 12, 2021 Fencl JL, Willoughby C, Jackson K. Just culture: the foundation of staff safety in the perioperative environment. AORN J. 2021;113(4):329-336. doi:10.1002/aorn.13352. https://psnet.ahrq.gov/issue/just-culture-foundation-sta…

9398. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60696/psn-pdf
      July 15, 2020 - Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries. July 15, 2020 de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 119. https://psnet.ahrq.gov/…

9399. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/862999/psn-pdf
      February 21, 2024 - Health tech hazards: at-home medical devices, AI governance on ECRI's new list. February 21, 2024 Miliard M. Healthcare IT News. February 1, 2024. https://psnet.ahrq.gov/issue/health-tech-hazards-home-medical-devices-ai-governance-ecris-new-list Technologies provide improvements and introduce unique problems to ca…

9400. 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…