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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39085/psn-pdf
    November 11, 2009 - Integrating ethics and patient safety: the role of clinical ethics consultants in quality improvement. November 11, 2009 Opel DJ, Brownstein D, Diekema DS, et al. Integrating ethics and patient safety: the role of clinical ethics consultants in quality improvement. J Clin Ethics. 2009;20(3):220-6. https://psnet.ah…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40447/psn-pdf
    March 04, 2015 - Analysis and prioritization of near-miss adverse events in a radiology department. March 4, 2015 Thornton RH, Miransky J, Killen A, et al. Analysis and prioritization of near-miss adverse events in a radiology department. AJR Am J Roentgenol. 2011;196(5):1120-4. doi:10.2214/AJR.10.5373. https://psnet.ahrq.gov/issu…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42387/psn-pdf
    December 30, 2014 - 'Bad apples': time to redefine as a type of systems problem? December 30, 2014 Shojania KG, Dixon-Woods M. 'Bad apples': time to redefine as a type of systems problem? BMJ Qual Saf. 2013;22(7):528-531. doi:10.1136/bmjqs-2013-002138. https://psnet.ahrq.gov/issue/bad-apples-time-redefine-type-systems-problem While …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45587/psn-pdf
    January 23, 2017 - Comparison of physician and computer diagnostic accuracy. January 23, 2017 Semigran HL, Levine DM, Nundy S, et al. Comparison of Physician and Computer Diagnostic Accuracy. JAMA Intern Med. 2016;176(12):1860-1861. doi:10.1001/jamainternmed.2016.6001. https://psnet.ahrq.gov/issue/comparison-physician-and-computer-d…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837001/psn-pdf
    April 27, 2022 - Final Report of the Ockenden Review. April 27, 2022 London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294. https://psnet.ahrq.gov/issue/final-report-ockenden-review Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves as the final conclusions of an i…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47765/psn-pdf
    February 20, 2019 - Negative behaviours in health care: prevalence and strategies. February 20, 2019 Layne DM, Nemeth LS, Mueller M, et al. Negative behaviours in health care: Prevalence and strategies. J Nurs Manag. 2019;27(1):154-160. doi:10.1111/jonm.12660. https://psnet.ahrq.gov/issue/negative-behaviours-health-care-prevalence-an…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45427/psn-pdf
    October 19, 2016 - How to monitor patient safety in primary care? Healthcare professionals' views. October 19, 2016 Samra R, Car J, Majeed A, et al. How to monitor patient safety in primary care? Healthcare professionals' views. JRSM Open. 2016;7(8):2054270416648045. doi:10.1177/2054270416648045. https://psnet.ahrq.gov/issue/how-mon…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836832/psn-pdf
    March 30, 2022 - Improving Education—A Key to Better Diagnostic Outcomes. March 30, 2022 Olson APJ, Danielson J, Stanley J, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2022. AHRQ Publication No. 22-0026-1-EF https://psnet.ahrq.gov/issue/improving-education-key-better-diagnostic-outcomes Diagnostic skil…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47321/psn-pdf
    June 19, 2019 - Validation of a mobile app for reducing errors of administration of medications in an emergency. June 19, 2019 Baumann D, Dibbern N, Sehner S, et al. Validation of a mobile app for reducing errors of administration of medications in an emergency. J Clin Monit Comput. . 2019;33(3):531-539. doi:10.1007/s10877-018-018…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37479/psn-pdf
    February 22, 2011 - Performance of a web-based clinical diagnosis support system for internists. February 22, 2011 Graber ML, Mathew A. Performance of a web-based clinical diagnosis support system for internists. J Gen Intern Med. 2008;23 Suppl 1:37-40. doi:10.1007/s11606-007-0271-8. https://psnet.ahrq.gov/issue/performance-web-based…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42929/psn-pdf
    February 05, 2014 - Do no harm: is it time to rethink the Hippocratic Oath? February 5, 2014 Walton M, Kerridge I. Do no harm: is it time to rethink the Hippocratic Oath? Med Educ. 2014;48(1):17-27. doi:10.1111/medu.12275. https://psnet.ahrq.gov/issue/do-no-harm-it-time-rethink-hippocratic-oath This commentary discusses how health ca…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35039/psn-pdf
    February 24, 2019 - Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety. February 24, 2019 Litvak E, Buerhaus P, Davidoff F, et al. Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety. Jt Comm J Qual Patient Saf. 2005;31(6):330-8. ht…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46729/psn-pdf
    January 17, 2018 - Diagnostic error in pediatric cancer. January 17, 2018 Carberry AR, Hanson K, Flannery A, et al. Diagnostic Error in Pediatric Cancer. Clin Pediatr (Phila). 2017;57*1((1):11-18. doi:10.1177/0009922816687325. https://psnet.ahrq.gov/issue/diagnostic-error-pediatric-cancer Missed or delayed cancer diagnoses can lead …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50457/psn-pdf
    October 09, 2019 - Combined SNA and LDA methods to understand adverse medical events October 9, 2019 Zhu L, Reychav I, McHaney R, et al. Combined SNA and LDA methods to understand adverse medical events. Int J Risk Saf Med. 2019;30(3):129-153. doi:10.3233/JRS-180052. https://psnet.ahrq.gov/issue/combined-sna-and-lda-methods-understa…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36755/psn-pdf
    May 04, 2014 - Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan. May 4, 2014 Murphy JG, Stee LA, McEvoy MT, et al. Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan. Chest. 2007;131(3):890-896. doi:10.1378…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43877/psn-pdf
    February 25, 2015 - Training situational awareness to reduce surgical errors in the operating room. February 25, 2015 Graafland M, Schraagen JMC, Boermeester MA, et al. Training situational awareness to reduce surgical errors in the operating room. Br J Surg. 2015;102(1):16-23. doi:10.1002/bjs.9643. https://psnet.ahrq.gov/issue/train…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46036/psn-pdf
    July 05, 2017 - Operational failures detected by frontline acute care nurses. July 5, 2017 Stevens KR, Engh EP, Tubbs-Cooley HL, et al. Operational Failures Detected by Frontline Acute Care Nurses. Res Nurs Health. 2017;40(3):197-205. doi:10.1002/nur.21791. https://psnet.ahrq.gov/issue/operational-failures-detected-frontline-acut…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46465/psn-pdf
    February 21, 2018 - Preventing mistransfusions: an evaluation of institutional knowledge and a response. February 21, 2018 MacDougall N, Dong F, Broussard L, et al. Preventing Mistransfusions: An Evaluation of Institutional Knowledge and a Response. Anesth Analg. 2018;126(1):247-251. doi:10.1213/ANE.0000000000002443. https://psnet.ah…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46035/psn-pdf
    May 17, 2017 - Economic impact of medication error: a systematic review. May 17, 2017 Walsh EK, Hansen CR, Sahm LJ, et al. Economic impact of medication error: a systematic review. Pharmacoepidemiol Drug Saf. 2017;26(5):481-497. doi:10.1002/pds.4188. https://psnet.ahrq.gov/issue/economic-impact-medication-error-systematic-review…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35233/psn-pdf
    August 10, 2005 - The influence of the causes and contexts of medical errors on emergency medicine residents' responses to their errors: an exploration. August 10, 2005 Hobgood C, Hevia A, Tamayo-Sarver JH, et al. The influence of the causes and contexts of medical errors on emergency medicine residents' responses to their errors: …
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