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7941. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45176/psn-pdf
      July 20, 2016 - Sustaining Improvement. July 20, 2016 Scoville R, Little K, Rakover J, et al. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. https://psnet.ahrq.gov/issue/sustaining-improvement Numerous activities and programs have been launched to improve patient safety, but sustaining improvements can be …

7942. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40218/psn-pdf
      December 29, 2014 - Preventable adverse drug events and their causes and contributing factors: the analysis of register data. December 29, 2014 Jylhä V, Saranto K, Bates DW. Preventable adverse drug events and their causes and contributing factors: the analysis of register data. Int J Qual Health Care. 2011;23(2):187-97. doi:10.1093/i…

7943. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41279/psn-pdf
      September 19, 2016 - Medical error, incident investigation and the second victim: doing better but feeling worse? September 19, 2016 Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf. 2012;21(4):267-70. doi:10.1136/bmjqs-2011-000605. https://psnet.ahrq.gov/…

7944. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45450/psn-pdf
      February 13, 2018 - Avoiding Unconscious Bias: a Guide for Surgeons. February 13, 2018 London, UK: Royal College of Surgeons of England; 2016. https://psnet.ahrq.gov/issue/avoiding-unconscious-bias-guide-surgeons Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides information for sur…

7945. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60331/psn-pdf
      May 13, 2020 - How a Doctor Confronts Medical Error. May 13, 2020 People’s Pharmacy.  Show 1209. April 28, 2020. https://psnet.ahrq.gov/issue/how-doctor-confronts-medical-error Accidental harm to patients is a persistent challenge in health care. This interview features Dr. Danielle Ofri who provides an overview of error in…

7946. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46634/psn-pdf
      November 22, 2017 - Ambulatory Care Patient Safety 2017–2018. November 22, 2017 National Quality Forum; NQF. https://psnet.ahrq.gov/issue/ambulatory-care-patient-safety-2017-2018 Patient safety in ambulatory care is emerging as a focus of research, regulation, and measurement efforts. This website provides information and resources r…

7947. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837738/psn-pdf
      July 27, 2022 - High-reliability organisation principles implemented in dentistry. July 27, 2022 Minyé HM, Benjamin EM. High-reliability organisation principles implemented in dentistry. Br Dent J. 2022;232(12):879-885. doi:10.1038/s41415-022-4354-z. https://psnet.ahrq.gov/issue/high-reliability-organisation-principles-implemente…

7948. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48136/psn-pdf
      August 07, 2019 - Safe Practices for Drug Allergies—Using CDS and Health IT. August 7, 2019 Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2019. https://psnet.ahrq.gov/issue/safe-practices-drug-allergies-using-cds-and-health-it Inconsistent checking for and consideration of drug allergy alerts can d…

7949. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44100/psn-pdf
      June 10, 2015 - Residency training in handoffs: a survey of program directors in psychiatry. June 10, 2015 Arbuckle MR, Reardon CL, Young JQ. Residency training in handoffs: a survey of program directors in psychiatry. Acad Psychiatry. 2015;39(2):132-8. doi:10.1007/s40596-014-0167-y. https://psnet.ahrq.gov/issue/residency-trainin…

7950. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46687/psn-pdf
      February 21, 2018 - Oversedation of a patient with obstructive sleep apnea prior to imaging. February 21, 2018 Blay E, Barnard C, Bilimoria KY. Oversedation of a Patient With Obstructive Sleep Apnea Prior to Imaging. JAMA. 2018;319(5):495-496. doi:10.1001/jama.2017.22004. https://psnet.ahrq.gov/issue/oversedation-patient-obstructive-…

7951. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39267/psn-pdf
      April 01, 2010 - What have we learned about interventions to reduce medical errors? April 1, 2010 Woodward HI, Mytton OT, Lemer C, et al. What have we learned about interventions to reduce medical errors? Annu Rev Public Health. 2010;31:479-97 1 p following 497. doi:10.1146/annurev.publhealth.012809.103544. https://psnet.ahrq.gov…

7952. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43790/psn-pdf
      October 23, 2023 - Complaints to the Parliamentary and Health Service Ombudsman. October 23, 2023 Manchester, UK: Parliamentary and Health Service Ombudsman. https://psnet.ahrq.gov/issue/complaints-about-acute-trusts-2016-2017 The National Health Service broadly reports the results of system-level analyses and investigations into t…

7953. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45834/psn-pdf
      February 22, 2017 - Implementing an error disclosure coaching model: a multicenter case study. February 22, 2017 White AA, Brock DM, McCotter PI, et al. Implementing an error disclosure coaching model: A multicenter case study. J Healthc Risk Manag. 2017;36(3):34-45. doi:10.1002/jhrm.21260. https://psnet.ahrq.gov/issue/implementing-e…

7954. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39100/psn-pdf
      January 28, 2010 - Hospital governance and the quality of care. January 28, 2010 Jha AK, Epstein AM. Hospital governance and the quality of care. Health Aff (Millwood). 2010;29(1):182-7. doi:10.1377/hlthaff.2009.0297. https://psnet.ahrq.gov/issue/hospital-governance-and-quality-care This study surveyed more than 700 board chairs and…

7955. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39098/psn-pdf
      November 11, 2009 - Building team and technical competency for obstetric emergencies: the mobile obstetric emergencies simulator (MOES) system. November 11, 2009 Deering S, Rosen MA, Salas E, et al. Building team and technical competency for obstetric emergencies: the mobile obstetric emergencies simulator (MOES) system. Simul Health…

7956. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47668/psn-pdf
      January 30, 2019 - Organizing for Reliability: A Guide for Research and Practice. January 30, 2019 Ramanujam R, Roberts KH, eds. Stanford, CA: Stanford University Press; 2018. ISBN: 9780804793612. https://psnet.ahrq.gov/issue/organizing-reliability-guide-research-and-practice High reliability principles guide safety efforts in compl…

7957. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35079/psn-pdf
      November 04, 2015 - Medical Error: What Do We Know? What Do We Do? November 4, 2015 Rosenthal MM; Sutcliffe KM, eds. San Francisco, CA: Jossey-Bass; 2002. https://psnet.ahrq.gov/issue/medical-error-what-do-we-know-what-do-we-do Opening with a review of lessons learned since the Harvard Medical Practice Study (HMPS), this book explore…

7958. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47821/psn-pdf
      May 22, 2019 - Patient Safety. May 22, 2019 National Pharmacy Association; NPA. https://psnet.ahrq.gov/issue/patient-safety-15 This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It i…

7959. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47460/psn-pdf
      October 10, 2018 - A surgeon so bad it was criminal. October 10, 2018 Beil L. ProPublica. October 2, 2018. https://psnet.ahrq.gov/issue/surgeon-so-bad-it-was-criminal This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted…

7960. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42902/psn-pdf
      January 29, 2014 - Improving Patient Safety Through Teamwork and Team Training. January 29, 2014 Salas E, Frush K, eds. Oxford, UK: Oxford University Press; 2013. ISBN: 9780195399097. https://psnet.ahrq.gov/issue/improving-patient-safety-through-teamwork-and-team-training Health care has been recently been directed toward focusing o…