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61. Team situation awareness and the anticipation of patient progress during ICU rounds. | PSNet
    psnet.ahrq.gov/issue/team-situation-awareness-and-anticipation-patient-progress-during-icu-rounds
    May 06, 2009 - Situational awareness refers to the degree to which perception matches reality.

62. Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care. | PSNet
    psnet.ahrq.gov/issue/impact-non-interruptive-medication-laboratory-monitoring-alerts-ambulatory-care
    March 10, 2011 - "Alert fatigue" refers to the tendency of clinicians to ignore safety alerts —for example, warnings

63. Collective intelligence increases diagnostic accuracy in a general practice setting. | PSNet
    psnet.ahrq.gov/issue/collective-intelligence-increases-diagnostic-accuracy-general-practice-setting
    August 03, 2017 - Collective intelligence in diagnosis refers to the collaboration of multiple individuals to generate

64. Improvement Tools | PSNet
    psnet.ahrq.gov/improvement-tools
    February 26, 2025 - Failure to rescue typically refers to a health system’s slow or...

65. Psychological and psychosomatic symptoms of second victims of adverse events: a systematic review and meta-analysis. | PSNet
    psnet.ahrq.gov/issue/psychological-and-psychosomatic-symptoms-second-victims-adverse-events-systematic-review-and
    June 23, 2021 - The second victim phenomenon refers to the emotional impact adverse events and patient harm can have

66. The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. | PSNet
    psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa
    November 18, 2015 - Vaughan refers to this second tendency as the “ normalization of deviance ,” a phenomenon that shares

67. Supporting clinicians after adverse events: development of a clinician peer support program. | PSNet
    psnet.ahrq.gov/issue/supporting-clinicians-after-adverse-events-development-clinician-peer-support-program
    April 24, 2018 - The second victim phenomenon refers to the emotional and psychological toll experienced by clinicians

68. Comprehensive evaluation of using computerised provider order-entry system for hospital discharge orders. | PSNet
    psnet.ahrq.gov/issue/comprehensive-evaluation-using-computerised-provider-order-entry-system-hospital-discharge
    August 24, 2015 - Computerized provider order entry (CPOE) refers to a system in which clinicians directly place orders

69. Value of improving patient safety: health economic considerations for rapid response systems-a rapid review of the literature and expert round table. | PSNet
    psnet.ahrq.gov/issue/value-improving-patient-safety-health-economic-considerations-rapid-response-systems-rapid
    January 07, 2015 - Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead

70. Failure to rescue female patients undergoing high-risk surgery. | PSNet
    psnet.ahrq.gov/issue/failure-rescue-female-patients-undergoing-high-risk-surgery
    October 25, 2017 - Failure-to-rescue (FTR) refers to the idea that many complications of medical care are not preventable

71. Organisational culture: variation across hospitals and connection to patient safety climate. | PSNet
    psnet.ahrq.gov/issue/organisational-culture-variation-across-hospitals-and-connection-patient-safety-climate
    March 17, 2010 - culture includes domains relating to communication and teamwork between providers, organizational culture refers

72. Biases in detection of apparent "weekend effect" on outcome with administrative coding data: population based study of stroke. | PSNet
    psnet.ahrq.gov/issue/biases-detection-apparent-weekend-effect-outcome-administrative-coding-data-population-based
    September 23, 2020 - The weekend effect refers to the fact that mortality for several common conditions is higher in patients

73. Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals. | PSNet
    psnet.ahrq.gov/issue/weekend-effect-hospital-mortality-ischemic-and-hemorrhagic-stroke-us-rural-and-urban
    January 19, 2022 - The ” weekend effect ” refers to worse patient outcomes occurring outside of usual business hours.

74. Safety of overlapping surgery at a high-volume referral center. | PSNet
    psnet.ahrq.gov/issue/safety-overlapping-surgery-high-volume-referral-center
    January 11, 2017 - Overlapping surgery refers to when two procedures are performed concurrently, but important portions

75. Elevated mortality among weekend hospital admissions is not associated with adoption of seven day clinical standards. | PSNet
    psnet.ahrq.gov/issue/elevated-mortality-among-weekend-hospital-admissions-not-associated-adoption-seven-day
    July 21, 2017 - The weekend effect refers to higher rates of adverse outcomes experienced by patients admitted on

76. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/843150/psn-pdf
    December 05, 2022 - Transgender refers to people whose gender identity differs from the sex they were assigned at birth … The term transgender woman (or trans woman) refers to a woman assigned male at birth; transgender man … (or trans man) refers to a man assigned female at birth. … Gender-affirming care refers to care and surgical procedures that can help people adjust their bodies

77. The social cost of adverse medical events, and what we can do about it. | PSNet
    psnet.ahrq.gov/issue/social-cost-adverse-medical-events-and-what-we-can-do-about-it
    February 10, 2015 - In this context, the social cost refers to the economic costs associated with lives lost or injuries

78. Microsoft PowerPoint - FINAL Dec Spotlight_Code Status vs Care Status.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
    January 01, 2020 - . — Understanding refers to one’s ability to comprehend the information presented to them. … — Reasoning refers to one’s ability to compare the treatment options available and compare their risks … This dimension refers to the patient’s ability to come to a conclusion about the information presented

79. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33579/psn-pdf
    September 15, 2024 - The blunt end refers to the many layers of the health care system not in direct contact with patients … Schematic behavior refers to the many activities we perform reflexively, or as if acting on autopilot

80. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-472
    February 26, 2025 - Failure-to-rescue (FTR) refers to the idea that many complications of medical care are not preventable … Failure-to-rescue (FTR) refers to the idea that many complications of medical care are not preventable