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7881. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33922/psn-pdf
      August 05, 2009 - The importance of cognitive errors in diagnosis and strategies to minimize them. August 5, 2009 Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780. https://psnet.ahrq.gov/issue/importance-cognitive-errors-diagnosis-and-strategies-minimize-them…

7882. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836868/psn-pdf
      April 06, 2022 - HEAR Her Concerns. April 6, 2022 National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention.  https://psnet.ahrq.gov/issue/hear-her-concerns Maternal harm during and after pregnancy is a sentinel event. This campaign encoura…

7883. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35015/psn-pdf
      June 16, 2011 - Keeping Patients Safe: Transforming the Work Environment of Nurses. June 16, 2011 Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services. Washington, DC: The National Academies Press; 2004. ISBN: 9780309090674. https://psnet.ahrq.gov/issue/keeping-patients-safe-trans…

7884. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852458/psn-pdf
      June 01, 2019 - The patient's role in patient safety. June 1, 2019 Corina I, Abram M, Halperin D. The patient's role in patient safety. Obstet Gynecol Clin North Am. 2019;46(2):215-225. doi:10.1016/j.ogc.2019.01.004. https://psnet.ahrq.gov/issue/patients-role-patient-safety Patients and their families can play an important role i…

7885. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35523/psn-pdf
      December 14, 2010 - ISMP Medication Errors Reporting Program. December 14, 2010 Institute for Safe Medication Practices https://psnet.ahrq.gov/issue/ismp-medication-errors-reporting-program The Institute for Safe Medication Practices (ISMP) administers this national reporting program, which collects confidential reports of medication…

7886. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35327/psn-pdf
      March 15, 2017 - Common Program Requirements. The Learning and Working Environment (Duty Hours). March 15, 2017 Accreditation Council for Graduate Medical Education. https://psnet.ahrq.gov/issue/common-program-requirements-learning-and-working-environment-duty-hours This website provides information about efforts to study and set …

7887. 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 …

7888. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838147/psn-pdf
      July 01, 2020 - Care Compare. July 1, 2020 Centers for Medicare and Medicaid Services. https://psnet.ahrq.gov/issue/care-compare The Centers for Medicare & Medicaid Services (CMS) support transparency through the provision of publicly available information on the quality of health care service in the United States. This portal en…

7889. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47999/psn-pdf
      May 15, 2019 - Pregnancy-related deaths: saving women’s lives before, during and after delivery. May 15, 2019 CDC Vital Signs. May 7, 2019. https://psnet.ahrq.gov/issue/pregnancy-related-deaths-saving-womens-lives-during-and-after-delivery Maternal morbidity and mortality is a worldwide patient safety problem. This analysis desc…

7890. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38022/psn-pdf
      August 27, 2008 - Hospitals try to calm doctors' outbursts: medical road rage affecting patient safety, group says. August 27, 2008 Kowalczyk L. https://psnet.ahrq.gov/issue/hospitals-try-calm-doctors-outbursts-medical-road-rage-affecting-patient- safety-group-says This article describes how physician outbursts can affect patient …

7891. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37835/psn-pdf
      July 31, 2008 - Medical students' experiences with medical errors: an analysis of medical student essays. July 31, 2008 Martinez W, Lo B. Medical students' experiences with medical errors: an analysis of medical student essays. Med Educ. 2008;42(7):733-41. doi:10.1111/j.1365-2923.2008.03109.x. https://psnet.ahrq.gov/issue/medical…

7892. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43684/psn-pdf
      November 26, 2014 - Rapid response systems. November 26, 2014 Hillman KM, Chen J, Jones D. Rapid response systems. Med J Aust. 2014;201(9):519-21. https://psnet.ahrq.gov/issue/rapid-response-systems Rapid response systems have been widely accepted as a method to improve outcomes of hospitalized patients demonstrating signs of rapid d…

7893. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38835/psn-pdf
      September 02, 2009 - Impact of a computerized physician order entry system on compliance with prescription accuracy requirements. September 2, 2009 Mir C, Gadri A, Zelger GL, et al. Impact of a computerized physician order entry system on compliance with prescription accuracy requirements. Pharm World Sci. 2009;31(5):596-602. doi:10.10…

7894. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40447/psn-pdf
      March 04, 2015 - Analysis and prioritization of near-miss adverse events in a radiology department. March 4, 2015 Thornton RH, Miransky J, Killen A, et al. Analysis and prioritization of near-miss adverse events in a radiology department. AJR Am J Roentgenol. 2011;196(5):1120-4. doi:10.2214/AJR.10.5373. https://psnet.ahrq.gov/issu…

7895. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45747/psn-pdf
      December 21, 2016 - Implementing No Interruption Zones in the perioperative environment. December 21, 2016 Wright I. Implementing No Interruption Zones in the Perioperative Environment. AORN J. 2016;104(6):536- 540. doi:10.1016/j.aorn.2016.09.018. https://psnet.ahrq.gov/issue/implementing-no-interruption-zones-perioperative-environme…

7896. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836754/psn-pdf
      March 16, 2022 - State of science: evolving perspectives on ‘human error’. March 16, 2022 Read GJM, Shorrock S, Walker GH, et al. State of science: evolving perspectives on ‘human error’. Ergonomics. 2021;64(9):1091-1114. doi:10.1080/00140139.2021.1953615. https://psnet.ahrq.gov/issue/state-science-evolving-perspectives-human-error…

7897. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45968/psn-pdf
      October 24, 2024 - State of Care. October 24, 2024 Newcastle Upon Tyne, UK: Care Quality Commission; October 2024. https://psnet.ahrq.gov/issue/state-care This website provides access to an annual report that summarizes National Health Service hospital and social care performance across a range of care quality metrics at both the tr…

7898. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836787/psn-pdf
      December 01, 2021 - The second victim: a contested term? December 1, 2021 Tumelty M-E. The second victim: a contested term? J Patient Saf. 2021;17(8):e1488-e1493. doi:10.1097/pts.0000000000000558. https://psnet.ahrq.gov/issue/second-victim-contested-term There has been some controversy around the term ‘second victim.’ Based on qualit…

7899. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47050/psn-pdf
      April 18, 2018 - Improving Physician Well-Being, Restoring Meaning in Medicine. April 18, 2018 Accreditation Council for Graduate Medical Education. https://psnet.ahrq.gov/issue/physician-well-being Physician and resident well-being is receiving increased attention as an area of focus of the clinical learning environment. This we…

7900. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40183/psn-pdf
      February 02, 2011 - Nurses' work schedule characteristics, nurse staffing, and patient mortality. February 2, 2011 Trinkoff AM, Johantgen M, Storr CL, et al. Nurses' work schedule characteristics, nurse staffing, and patient mortality. Nurs Res. 2011;60(1):1-8. doi:10.1097/NNR.0b013e3181fff15d. https://psnet.ahrq.gov/issue/nurses-wor…