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9901. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45670/psn-pdf
      November 16, 2016 - Not thinking clearly? Play a game, seriously! November 16, 2016 Mohan D, Schell J, Angus DC. Not Thinking Clearly? Play a Game, Seriously!. JAMA. 2016;316(18):1867- 1868. doi:10.1001/jama.2016.14174. https://psnet.ahrq.gov/issue/not-thinking-clearly-play-game-seriously Heuristics enable experts to build off their …

9902. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47108/psn-pdf
      June 06, 2018 - Cognitive bias in clinical practice—nurturing healthy skepticism among medical students. June 6, 2018 Bhatti A. Cognitive bias in clinical practice - nurturing healthy skepticism among medical students. Adv Med Educ Pract. 2018;9:235-237. doi:10.2147/AMEP.S149558. https://psnet.ahrq.gov/issue/cognitive-bias-clinic…

9903. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47574/psn-pdf
      November 21, 2018 - The architecture of safety: an emerging priority for improving patient safety. November 21, 2018 Joseph A, Henriksen K, Malone E. The Architecture Of Safety: An Emerging Priority For Improving Patient Safety. Health Aff (Millwood). 2018;37(11):1884-1891. doi:10.1377/hlthaff.2018.0643. https://psnet.ahrq.gov/issue/…

9904. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47279/psn-pdf
      July 23, 2018 - No Place Like Home: Advancing the Safety of Care in the Home. July 23, 2018 Boston, MA: Institute for Healthcare Improvement; 2018. https://psnet.ahrq.gov/issue/no-place-home-advancing-safety-care-home The home care setting harbors unique challenges to patient safety. This report builds on a previous evidence ass…

9905. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34760/psn-pdf
      March 28, 2005 - Managing the Risks of Organizational Accidents. March 28, 2005 Reason JT. Aldershot, Hants, England: Ashgate: 1997. ISBN: 9781840141047 https://psnet.ahrq.gov/issue/managing-risks-organizational-accidents Written 7 years after the publication of Human Error, this book demonstrates Reason's thinking at its finest a…

9906. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43468/psn-pdf
      December 10, 2014 - Does compliance to patient safety tasks improve and sustain when radiotherapy treatment processes are standardized? December 10, 2014 Simons P, Houben R, Benders J, et al. Does compliance to patient safety tasks improve and sustain when radiotherapy treatment processes are standardized? Eur J Oncol Nurs. 2014;18(5…

9907. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45845/psn-pdf
      December 19, 2017 - You can't blame the wreck on the train. December 19, 2017 Potts JR. You can't blame the wreck on the train. Am J Surg. 2017;214(5):974-978. doi:10.1016/j.amjsurg.2016.11.046. https://psnet.ahrq.gov/issue/you-cant-blame-wreck-train Insufficient supervision can limit resident education, which may increase risks to p…

9908. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45351/psn-pdf
      July 20, 2016 - Building a Patient Safety Toolkit for use in general practice. July 20, 2016 Bell BG, Spencer R, Marsden K, et al. Building a Patient Safety Toolkit for use in general practice. InnovAiT. 2016;9(9):557-562. doi:10.1177/1755738016650468. https://psnet.ahrq.gov/issue/patient-safety-toolkit-general-practice Although…

9909. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35805/psn-pdf
      January 02, 2017 - Getting the board on board: engaging hospital boards in quality and patient safety. January 2, 2017 Joshi MS, Hines S. Getting the board on board: Engaging hospital boards in quality and patient safety. Jt Comm J Qual Patient Saf. 2006;32(4):179-87. https://psnet.ahrq.gov/issue/getting-board-board-engaging-hospita…

9910. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34807/psn-pdf
      January 01, 2019 - The Quality in Australian Health Care Study. November 18, 2015 Wilson RML, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust. 2019;163(9):458-471. doi:10.5694/j.1326-5377.1995.tb124691.x. https://psnet.ahrq.gov/issue/quality-australian-health-care-study In order to estimate pa…

9911. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44903/psn-pdf
      September 27, 2016 - What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings. September 27, 2016 Allard J, Bleakley A. What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down gov…

9912. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34013/psn-pdf
      December 22, 2008 - Defining and measuring patient safety. December 22, 2008 Pronovost P, Thompson DA, Holzmueller CG, et al. Defining and measuring patient safety. Crit Care Clin. 2005;21(1):1-19, vii. https://psnet.ahrq.gov/issue/defining-and-measuring-patient-safety This review discusses the increasing demand for improving patient…

9913. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866254/psn-pdf
      July 10, 2024 - Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. July 10, 2024 Massey W, Keith C. Spotlight PA: June 20, 2024. https://psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems- months-shutdown-then Whistleblowers…

9914. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46086/psn-pdf
      August 30, 2017 - Quality and Safety in Nursing: a Competency Approach to Improving Outcomes, Second Edition. August 30, 2017 Sherwood G, Barnsteiner J, eds. Hoboken, NJ: Wiley-Blackwell; 2017. ISBN: 9781119151678. https://psnet.ahrq.gov/issue/quality-and-safety-nursing-competency-approach-improving-outcomes-second- edition The Cr…

9915. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861280/psn-pdf
      January 24, 2024 - Factors influencing diagnostic accuracy among intensive care unit clinicians - an observational study. January 24, 2024 Bergl PA, Shukla N, Shah J, et al. Factors influencing diagnostic accuracy among intensive care unit clinicians – an observational study. Diagnosis (Berl). 2024;11(1):31-39. doi:10.1515/dx-2023-00…

9916. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44027/psn-pdf
      April 15, 2015 - Hospital credentialing and privileging of surgeons: a potential safety blind spot. April 15, 2015 Pradarelli J, Campbell D, Dimick JB. Hospital credentialing and privileging of surgeons: a potential safety blind spot. JAMA. 2015;313(13):1313-4. doi:10.1001/jama.2015.1943. https://psnet.ahrq.gov/issue/hospital-cred…

9917. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47256/psn-pdf
      October 03, 2018 - Does the perception of severity of medical error differ between varying levels of clinical seniority? October 3, 2018 Khan I, Arsanious M. Does the perception of severity of medical error differ between varying levels of clinical seniority? Adv Med Educ Pract. 2018;9:443-452. doi:10.2147/AMEP.S146474. https://psne…

9918. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45274/psn-pdf
      July 20, 2016 - Medication safety in neonatal care: a review of medication errors among neonates. July 20, 2016 Krzyzaniak N, Bajorek B. Medication safety in neonatal care: a review of medication errors among neonates. Ther Adv Drug Saf. 2016;7(3):102-119. doi:10.1177/2042098616642231. https://psnet.ahrq.gov/issue/medication-safe…

9919. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72830/psn-pdf
      March 10, 2021 - Families are struggling to use medicines at home — we must truly involve them in their own safety. March 10, 2021 Morris S, O’Hara J. Pharmacuetical Journal. February 26, 2021. https://psnet.ahrq.gov/issue/families-are-struggling-use-medicines-home-we-must-truly-involve-them-their- own-safety It is a ch…

9920. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45276/psn-pdf
      September 29, 2017 - Clinicians' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. September 29, 2017 Hoffmann TC, Del Mar C. Clinicians' Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review. JAMA Intern Med. 2017;177(3):407-419. doi:10.1001/jama…