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psnet.ahrq.gov/node/39912/psn-pdf
October 06, 2010 - What the doctor missed.
October 6, 2010
https://psnet.ahrq.gov/issue/what-doctor-missed
Reporting how malpractice claims have exposed the frequency of diagnostic errors, this
newspaper article discusses steps hospitals and insurance companies are taking to reduce such errors.
https://psnet.ahrq.gov/issue/what-doct…
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psnet.ahrq.gov/issue/spectrum-medical-errors-when-patients-sue
October 28, 2020 - Review
The spectrum of medical errors: when patients sue.
Citation Text:
Grant-Kels J, Kels B. The spectrum of medical errors: when patients sue. Int J Gen Med. 2012. doi:10.2147/ijgm.s24257.
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psnet.ahrq.gov/issue/swift-new-tool-identifying-prospective-hazards
February 03, 2021 - Commentary
Beyond FMEA: the structured what-if technique (SWIFT).
Citation Text:
Card AJ, Ward JR, Clarkson PJ. Beyond FMEA: The structured what-if technique (SWIFT). J Healthc Risk Manag. 2012;31(4):23-29. doi:10.1002/jhrm.20101.
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psnet.ahrq.gov/issue/incidence-diagnostic-error-medicine
July 15, 2015 - Review
The incidence of diagnostic error in medicine.
Citation Text:
Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013;22 Suppl 2:ii21-ii27. doi:10.1136/bmjqs-2012-001615.
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psnet.ahrq.gov/issue/becoming-high-reliability-organization-through-shared-learning-safety-events
February 12, 2020 - Newspaper/Magazine Article
Becoming a high-reliability organization through shared learning of safety events
Citation Text:
Becoming a high-reliability organization through shared learning of safety events Klenklen J. Patient Saf Qual HCare. December 19, 2019.
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psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition
January 27, 2016 - Book/Report
Classic
Respectful Management of Serious Clinical Adverse Events. Second Edition.
Citation Text:
Respectful Management of Serious Clinical Adverse Events. Second Edition. Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Heal…
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psnet.ahrq.gov/issue/accelerating-what-works-using-qualitative-research-methods-developing-change-package-learning
November 25, 2009 - Commentary
Accelerating what works: using qualitative research methods in developing a change package for a learning collaborative.
Citation Text:
Sorensen A, Bernard SL. Accelerating what works: using qualitative research methods in developing a change package for a learning collaborati…
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psnet.ahrq.gov/issue/national-trauma-care-system-integrating-military-and-civilian-trauma-systems-achieve-zero
September 12, 2018 - Book/Report
A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.
Citation Text:
A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Nat…
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psnet.ahrq.gov/issue/improvement-guide-practical-approach-enhancing-organizational-performance-2nd-ed
November 29, 2017 - Book/Report
Classic
The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed.
Citation Text:
The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. Langley GJ, Moen R, Nolan KM, et al. Ho…
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psnet.ahrq.gov/issue/transitioning-newborns-nicu-home-resource-toolkit
August 01, 2012 - Government Resource
Transitioning Newborns From NICU to Home: A Resource Toolkit.
Citation Text:
Transitioning Newborns From NICU to Home: A Resource Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; December 2013. AHRQ Publication No. 12(14)-0054-EF.
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psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands
February 16, 2011 - Commentary
System failure versus personal accountability--the case for clean hands.
Citation Text:
Goldmann DA. System failure versus personal accountability--the case for clean hands. N Engl J Med. 2006;355(2):121-3.
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psnet.ahrq.gov/issue/effect-nurse-staffing-patterns-medical-errors-and-nurse-burnout
October 11, 2023 - Review
The effect of nurse staffing patterns on medical errors and nurse burnout.
Citation Text:
Garrett C. The effect of nurse staffing patterns on medical errors and nurse burnout. AORN J. 2008;87(6):1191-204. doi:10.1016/j.aorn.2008.01.022.
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psnet.ahrq.gov/issue/meeting-moment-addressing-barriers-and-facilitating-clinical-adoption-artificial-intelligence
September 19, 2018 - Book/Report
Meeting the Moment: Addressing Barriers and Facilitating Clinical Adoption of Artificial Intelligence in Medical Diagnosis.
Citation Text:
Meeting the Moment: Addressing Barriers and Facilitating Clinical Adoption of Artificial Intelligence in Medical Diagnosis. Adler-Milstei…
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psnet.ahrq.gov/issue/defensive-medicine-among-high-risk-specialist-physicians-volatile-malpractice-environment
February 17, 2011 - Study
Defensive medicine among high-risk specialist physicians in a volatile malpractice environment.
Citation Text:
Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005;293(21):2609-17.
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psnet.ahrq.gov/issue/learning-candour-and-accountability-review-way-nhs-trusts-review-and-investigate-deaths
January 23, 2019 - Book/Report
Learning, Candour and Accountability. A Review of the Way NHS Trusts Review and Investigate the Deaths of Patients in England.
Citation Text:
Learning, Candour and Accountability. A Review of the Way NHS Trusts Review and Investigate the Deaths of Patients in England. Newcast…
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psnet.ahrq.gov/issue/medication-safety-issue-brief-look-alike-sound-alike-drugs
June 17, 2014 - Newspaper/Magazine Article
Medication safety issue brief. Look-alike, sound-alike drugs.
Citation Text:
Association AH, Pharmacists AS of H-S, Networks H & H. Medication safety issue brief, look-alike, sound-alike drugs. Hospitals and Health Networks. October 2005;79(10):57-58.
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psnet.ahrq.gov/issue/families-are-struggling-use-medicines-home-we-must-truly-involve-them-their-own-safety
February 02, 2022 - Newspaper/Magazine Article
Families are struggling to use medicines at home — we must truly involve them in their own safety.
Citation Text:
Families are struggling to use medicines at home — we must truly involve them in their own safety. Morris S, O’Hara J. Pharmacuetical Journal.…
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psnet.ahrq.gov/issue/simple-checklist-preventing-major-complications-associated-cesarean-delivery
January 10, 2024 - Commentary
A simple checklist for preventing major complications associated with cesarean delivery.
Citation Text:
Duff P. A simple checklist for preventing major complications associated with cesarean delivery. Obstet Gynecol. 2010;116(6):1393-1396. doi:10.1097/AOG.0b013e3181fae763.
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psnet.ahrq.gov/issue/adherence-medication-safety-protocol-current-practice-labeling-medications-and-solutions
July 19, 2023 - Study
Adherence to a medication safety protocol: current practice for labeling medications and solutions on the sterile field.
Citation Text:
Brown-Brumfield D, DeLeon A. Adherence to a medication safety protocol: current practice for labeling medications and solutions on the sterile f…
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psnet.ahrq.gov/issue/when-diagnostic-testing-leads-harm-new-outcomes-based-approach-laboratory-medicine
September 12, 2018 - Commentary
When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine.
Citation Text:
Epner PL, Gans JE, Graber ML. When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine. BMJ Qual Saf. 2013;22 Suppl 2:ii6-ii10. d…