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psnet.ahrq.gov/glossary/failure-mode-and-effect-analysis-fmeaSeptember 13, 2021 - Failure Mode and Effect Analysis (FMEA) September 13, 2021 Anonymous (not verified) A common process used to prospectively identify error risk within a particular process. FMEA begins with a complete process mapping that identifies all the steps that must occur for a given process to occur (e.g., programming an…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46108/psn-pdfDecember 21, 2017 - Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents. December 21, 2017 Martinez W, Lehmann LS, Thomas EJ, et al. Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents. BMJ… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43723/psn-pdfOctober 03, 2017 - Shining a Light: Safer Health Care Through Transparency. October 3, 2017 Boston, MA: National Patient Safety Foundation Lucian Leape Institute; January 2015. https://psnet.ahrq.gov/issue/shining-light-safer-health-care-through-transparency Health care has historically treated data as something to be safeguarded rat… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37613/psn-pdfMarch 12, 2008 - Implementing patient safety interventions in your hospital: what to try and what to avoid. March 12, 2008 Ranji SR, Shojania KG. Implementing patient safety interventions in your hospital: what to try and what to avoid. Med Clin North Am. 2008;92(2):275-93, vii-viii. doi:10.1016/j.mcna.2007.10.007. https://psnet.a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42855/psn-pdfFebruary 06, 2014 - Responding to clinicians who fail to follow patient safety practices: perceptions of physicians, nurses, trainees, and patients. February 6, 2014 Driver TH, Katz PP, Trupin L, et al. Responding to clinicians who fail to follow patient safety practices: perceptions of physicians, nurses, trainees, and patients. J H… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43869/psn-pdfNovember 03, 2015 - Clinical safety of England's national programme for IT: a retrospective analysis of all reported safety events 2005 to 2011. November 3, 2015 Magrabi F, Baker M, Sinha I, et al. Clinical safety of England's national programme for IT: a retrospective analysis of all reported safety events 2005 to 2011. Int J Med In… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43115/psn-pdfDecember 18, 2014 - Multistate point-prevalence survey of health care- associated infections. December 18, 2014 Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13):1198-208. doi:10.1056/NEJMoa1306801. https://psnet.ahrq.gov/issue/multistate-point… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50368/psn-pdfSeptember 25, 2019 - A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers. September 25, 2019 Bourgeois FC, Fossa A, Gerard M, et al. A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers. J Am Med Inform As… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47908/psn-pdfApril 24, 2019 - "Sorry" is never enough: how state apology laws fail to reduce medical malpractice liability risk. April 24, 2019 McMichael BJ, Van Horn L, Viscusi K. "Sorry” Is Never Enough: How State Apology Laws Fail to Reduce Medical Malpractice Liability Risk. Stanford Law Rev. 2019;71(2):341-409. https://psnet.ahrq.gov/issu… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38902/psn-pdfNovember 13, 2009 - Out-of-hospital medication errors: a 6-year analysis of the national poison data system. November 13, 2009 Shah K, Barker KA. Out-of-hospital medication errors: a 6-year analysis of the national poison data system. Pharmacoepidemiol Drug Saf. 2009;18(11):1080-5. doi:10.1002/pds.1823. https://psnet.ahrq.gov/issue/o… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46493/psn-pdfJanuary 24, 2019 - Four states with robust prescription drug monitoring programs reduced opioid dosages. January 24, 2019 Haffajee RL, Mello MM, Zhang F, et al. Four States With Robust Prescription Drug Monitoring Programs Reduced Opioid Dosages. Health Aff (Millwood). 2018;37(6):964-974. doi:10.1377/hlthaff.2017.1321. https://psnet… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43049/psn-pdfOctober 31, 2014 - Vital signs: improving antibiotic use among hospitalized patients. October 31, 2014 Fridkin SK, Baggs J, Fagan R, et al. Vital signs: improving antibiotic use among hospitalized patients. MMWR Morb Mortal Wkly Rep. 2014;63(9):194-200. https://psnet.ahrq.gov/issue/vital-signs-improving-antibiotic-use-among-hospital… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47333/psn-pdfOctober 10, 2018 - Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. October 10, 2018 Jalal H, Buchanich JM, Roberts MS, et al. Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. Science (1979). 2018;361(6408). doi:10.1126/science.aau1184. https://p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47946/psn-pdfMay 22, 2019 - Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013- 2017. May 22, 2019 Petersen EE, Davis NL, Goodman D, et al. Vital Signs: Pregnancy-Related Deaths, United States, 2011- 2015, and Strategies for Prevention, 13 States, 2013-2017. MMWR Morb Mortal Wkly R… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47441/psn-pdfSeptember 26, 2018 - Patient outcomes after the introduction of statewide ICU nurse staffing regulations. September 26, 2018 Law AC, Stevens JP, Hohmann S, et al. Patient Outcomes After the Introduction of Statewide ICU Nurse Staffing Regulations. Crit Care Med. 2018;46(10):1563-1569. doi:10.1097/CCM.0000000000003286. https://psnet.ah… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45863/psn-pdfAugust 28, 2017 - Large-scale implementation of the I-PASS handover system at an academic medical centre. August 28, 2017 Shahian DM, McEachern K, Rossi L, et al. Large-scale implementation of the I-PASS handover system at an academic medical centre. BMJ Qual Saf. 2017;26(9):760-770. doi:10.1136/bmjqs-2016-006195. https://psnet.ahr… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/42966/psn-pdfNovember 21, 2018 - The next organizational challenge: finding and addressing diagnostic error. November 21, 2018 Graber ML, Trowbridge RL, Myers JS, et al. The next organizational challenge: finding and addressing diagnostic error. Jt Comm J Qual Patient Saf. 2014;40(3):102-10. https://psnet.ahrq.gov/issue/next-organizational-challe… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44522/psn-pdfJune 21, 2016 - Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis. June 21, 2016 Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop com… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45744/psn-pdfDecember 19, 2017 - Complication rates, hospital size, and bias in the CMS Hospital-Acquired Condition Reduction Program. December 19, 2017 Koenig L, Soltoff SA, Demiralp B, et al. Complication Rates, Hospital Size, and Bias in the CMS Hospital- Acquired Condition Reduction Program. Am J Med Qual. 2017;32(6):611-616. doi:10.1177/1062… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/40213/psn-pdfFebruary 16, 2011 - Systematic review of medication safety assessment methods. February 16, 2011 Meyer-Massetti C, Cheng CM, Schwappach DLB, et al. Systematic review of medication safety assessment methods. Am J Health Syst Pharm. 2011;68(3):227-40. doi:10.2146/ajhp100019. https://psnet.ahrq.gov/issue/systematic-review-medication-saf…
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