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psnet.ahrq.gov/node/48097/psn-pdf
July 17, 2019 - Serious misdiagnosis-related harms in malpractice
claims: the "Big Three": vascular events, infections, and
cancers.
July 17, 2019
Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Serious misdiagnosis-related harms in malpractice
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March 20, 2019 - Bachelor's degree nurse graduates report better quality
and safety educational preparedness than associate
degree graduates.
March 20, 2019
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psnet.ahrq.gov/glossary/swiss-cheese-model
September 13, 2021 - Swiss Cheese Model
September 13, 2021
Anonymous (not verified)
Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safe…
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psnet.ahrq.gov/node/44305/psn-pdf
January 22, 2016 - National incidence of medication error in surgical patients
before and after Accreditation Council for Graduate
Medical Education duty-hour reform.
January 22, 2016
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients
Before and After Accreditation Council for Gra…
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June 22, 2017 - Workarounds to hospital electronic prescribing systems:
a qualitative study in English hospitals.
June 22, 2017
Cresswell K, Mozaffar H, Lee L, et al. Workarounds to hospital electronic prescribing systems: a qualitative
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May 26, 2010 - Simulation-based training improves physicians'
performance in patient care in high-stakes clinical setting
of cardiac surgery.
May 26, 2010
Bruppacher HR, Alam SK, LeBlanc VR, et al. Simulation-based training improves physicians' performance
in patient care in high-stakes clinical setting of cardiac surgery. Anest…
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psnet.ahrq.gov/node/47088/psn-pdf
May 02, 2018 - Medical Office Survey on Patient Safety Culture: 2018
User Database Report.
May 2, 2018
Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April
2018. AHRQ Publication No. 18-0030-EF.
https://psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture-2018-user-dat…
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psnet.ahrq.gov/node/47150/psn-pdf
November 21, 2018 - Investigating the association of alerts from a national
mortality surveillance system with subsequent hospital
mortality in England: an interrupted time series analysis.
November 21, 2018
Cecil E, Bottle A, Esmail A, et al. Investigating the association of alerts from a national mortality
surveillance system with …
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October 30, 2010 - The harm susceptibility model: a method to prioritise
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October 30, 2010
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December 22, 2010 - The value of adding a verbal report to written handoffs on
early readmission following prolonged respiratory failure.
December 22, 2010
Hess DR, Tokarczyk A, O'Malley M, et al. The value of adding a verbal report to written handoffs on early
readmission following prolonged respiratory failure. Chest. 2010;138(6):14…
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September 21, 2016 - The well-defined pediatric ICU: active surveillance using
nonmedical personnel to capture less serious safety
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September 21, 2016
White WA, Kennedy K, Belgum HS, et al. The Well-Defined Pediatric ICU: Active Surveillance Using
Nonmedical Personnel to Capture Less Serious Safety Events. Jt Comm J Qual Patien…
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November 03, 2015 - The July effect: an analysis of never events in the
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June 28, 2017 - Early death after discharge from emergency departments:
analysis of national US insurance claims data.
June 28, 2017
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February 17, 2011 - The disclosure dilemma—large-scale adverse events.
February 17, 2011
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Error disc…
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January 25, 2017 - Economic evaluation of quality improvement
interventions for bloodstream infections related to central
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January 25, 2017
Nuckols TK, Keeler E, Morton SC, et al. Economic Evaluation of Quality Improvement Interventions for
Bloodstream Infections Related to Central Catheters: A Systema…
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August 20, 2018 - Effect of standardized handoff curriculum on improved
clinician preparedness in the intensive care unit: a
stepped-wedge cluster randomized clinical trial.
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March 20, 2018 - Impact of initial hospital diagnosis on mortality for acute
myocardial infarction: a national cohort study.
March 20, 2018
Wu J, Gale CP, Hall M, et al. Editor's Choice - Impact of initial hospital diagnosis on mortality for acute
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psnet.ahrq.gov/web-mm/surprise-wire
July 15, 2020 - Surprise Wire
Citation Text:
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/33754/psn-pdf
September 01, 2013 - Because
not only who gets the power to make that judgment but who is represented there?
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Browse Author Resources
Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …