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  1. Medical Device Use Error: Root Cause Analysis. | PSNet

    psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis
    January 10, 2018 - Book/Report Medical Device Use Error: Root Cause Analysis. Citation Text: Medical Device Use Error: Root Cause Analysis. Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790. Copy Citation Save Save to your library Print Down…

  2. Using medical-error reporting to drive patient safety efforts. | PSNet

    psnet.ahrq.gov/issue/using-medical-error-reporting-drive-patient-safety-efforts
    September 18, 2024 - Commentary Using medical-error reporting to drive patient safety efforts. Citation Text: Stow J. Using medical-error reporting to drive patient safety efforts. AORN J. 2006;84(3):406-8, 411-4, 417-20; quiz 421-4. Copy Citation Format: Google Scholar PubMed BibTeX EndNote …

  3. Patient Safety and the "Just Culture": A Primer for Health Care Executives. | PSNet

    psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-executives
    July 24, 2013 - Book/Report Classic Patient Safety and the "Just Culture": A Primer for Health Care Executives. Citation Text: Marx DA. Patient Safety And The "Just Culture": A Primer For Health Care Executives. New York, NY: Trustees of Columbia University; 2001. Copy Citati…

  4. Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders. | PSNet

    psnet.ahrq.gov/issue/rethinking-patient-safety-discussion-guide-patients-healthcare-providers-and-leaders
    August 24, 2022 - Toolkit Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders. Citation Text: Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders. Gilbert R, Asselbergs M, Davis D, et al. Healthcare Excellence Canada; 2023. …

  5. Why diagnostic errors don't get any respect--and what can be done about them. | PSNet

    psnet.ahrq.gov/issue/why-diagnostic-errors-dont-get-any-respect-and-what-can-be-done-about-them
    February 10, 2015 - Commentary Why diagnostic errors don't get any respect--and what can be done about them. Citation Text: Wachter RM. Why Diagnostic Errors Don’t Get Any Respect—And What Can Be Done About Them. Health Aff (Millwood). 2010;29(9):1605-1610. doi:10.1377/hlthaff.2009.0513. Copy Citation …

  6. Keeping Patients Safe: Transforming the Work Environment of Nurses. | PSNet

    psnet.ahrq.gov/issue/keeping-patients-safe-transforming-work-environment-nurses
    July 05, 2016 - Book/Report Classic Keeping Patients Safe: Transforming the Work Environment of Nurses. Citation Text: Keeping Patients Safe: Transforming the Work Environment of Nurses. Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Healt…

  7. Mitigating hazards through continuing design: the birth and evolution of a pediatric intensive care unit. | PSNet

    psnet.ahrq.gov/issue/mitigating-hazards-through-continuing-design-birth-and-evolution-pediatric-intensive-care
    April 06, 2011 - Commentary Mitigating hazards through continuing design: the birth and evolution of a pediatric intensive care unit. Citation Text: Madsen P, Desai V, Roberts K, et al. Mitigating Hazards Through Continuing Design: The Birth and Evolution of a Pediatric Intensive Care Unit. Organizati…

  8. Implementing hospital-based communication-and-resolution programs: lessons learned in New York City. | PSNet

    psnet.ahrq.gov/issue/implementing-hospital-based-communication-and-resolution-programs-lessons-learned-new-york
    September 01, 2018 - Study Implementing hospital-based communication-and-resolution programs: lessons learned in New York City. Citation Text: Mello MM, Senecal SK, Kuznetsov Y, et al. Implementing hospital-based communication-and-resolution programs: lessons learned in New York City. Health Aff (Millwood).…

  9. Set Phasers on Stun: And Other True Tales of Design, Technology, and Human Error, Second Edition. | PSNet

    psnet.ahrq.gov/issue/set-phasers-stun-and-other-true-tales-design-technology-and-human-error-second-edition
    May 30, 2019 - Book/Report Classic Set Phasers on Stun: And Other True Tales of Design, Technology, and Human Error, Second Edition. Citation Text: Set Phasers on Stun: And Other True Tales of Design, Technology, and Human Error, Second Edition. Casey SM. Santa Barbara, CA: Ae…

  10. State of science: human factors and ergonomics in healthcare. | PSNet

    psnet.ahrq.gov/issue/state-science-human-factors-and-ergonomics-healthcare
    April 01, 2015 - Commentary State of science: human factors and ergonomics in healthcare. Citation Text: Hignett S, Carayon P, Buckle P, et al. State of science: human factors and ergonomics in healthcare. Ergonomics. 2013;56(10):1491-503. doi:10.1080/00140139.2013.822932. Copy Citation Format: …

  11. Ambiguity and workarounds as contributors to medical error. | PSNet

    psnet.ahrq.gov/issue/ambiguity-and-workarounds-contributors-medical-error
    December 23, 2008 - Commentary Ambiguity and workarounds as contributors to medical error. Citation Text: Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med. 2005;142(8):627-630. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XM…

  12. Health information technology-related wrong-patient errors: context is critical. | PSNet

    psnet.ahrq.gov/issue/health-information-technology-related-wrong-patient-errors-context-critical
    June 01, 2022 - Study Health information technology-related wrong-patient errors: context is critical. Citation Text: Health information technology-related wrong-patient errors: context is critical. Kim T, Howe J, Franklin E, et al. Patient Safety. 2020;2(4):40–57.    Copy Citation …

  13. Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. | PSNet

    psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
    May 30, 2012 - Multi-use Website Classic Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. Citation Text: Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. The Joint Commission. Copy Citation …

  14. Systems Analysis of Critical Incidents: the London Protocol. | PSNet

    psnet.ahrq.gov/issue/systems-analysis-critical-incidents-london-protocol
    April 06, 2016 - Book/Report Systems Analysis of Critical Incidents: the London Protocol. Citation Text: Systems Analysis of Critical Incidents: the London Protocol. Taylor-Adams S, Vincent C. London, UK: NIHR North West London Patient Safety Research Collaboration, Imperial College London; 2024. Copy …

  15. Implementing patient safety and quality improvement in dermatology. | PSNet

    psnet.ahrq.gov/issue/implementing-patient-safety-and-quality-improvement-dermatology
    September 30, 2015 - Commentary Implementing patient safety and quality improvement in dermatology. Citation Text: Implementing patient safety and quality improvement in dermatology. Marsch A, Khodosh R, Porter M, et al. J Am Acad Dermatol. 2023;89(4):641-54; 57-67. Copy Citation Save …

  16. Medical error and human factors engineering: where are we now? | PSNet

    psnet.ahrq.gov/issue/medical-error-and-human-factors-engineering-where-are-we-now
    August 04, 2021 - Review Medical error and human factors engineering: where are we now? Citation Text: Gawron VJ, Drury CG, Fairbanks RJ, et al. Medical error and human factors engineering: where are we now? Am J Med Qual. 2006;21(1):57-67. Copy Citation Format: Google Scholar PubMed BibTe…

  17. Case study: identifying potential problems at the human/technical interface in complex clinical systems. | PSNet

    psnet.ahrq.gov/issue/case-study-identifying-potential-problems-humantechnical-interface-complex-clinical-systems
    July 22, 2009 - Commentary Case study: identifying potential problems at the human/technical interface in complex clinical systems. Citation Text: Caudill-Slosberg M, Weeks WB. Case study: identifying potential problems at the human/technical interface in complex clinical systems. Am J Med Qual. 2005;…

  18. Understanding and responding to adverse events. | PSNet

    psnet.ahrq.gov/issue/understanding-and-responding-adverse-events
    July 19, 2019 - Commentary Classic Understanding and responding to adverse events. Citation Text: Vincent CA. Understanding and Responding to Adverse Events. New Engl J Med. 2003;348(11):1051-1056. doi:10.1056/nejmhpr020760. Copy Citation Format: DOI Google Scho…

  19. Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012. | PSNet

    psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-safety-2012
    November 02, 2012 - Book/Report Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012. Citation Text: Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012. Oakbrook Terrace, IL: The Joint Commission; September 2012. C…

  20. Error in medicine. | PSNet

    psnet.ahrq.gov/issue/error-medicine
    November 02, 2014 - Commentary Classic Error in medicine. Citation Text: Leape L. Error in medicine. JAMA. 1994;272(23):1851-1857. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation …
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