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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41438/psn-pdf
    January 03, 2017 - Implementing SBAR across a large multihospital health system. January 3, 2017 Compton J, Copeland K, Flanders S, et al. Implementing SBAR across a large multihospital health system. Jt Comm J Qual Patient Saf. 2012;38(6):261-8. https://psnet.ahrq.gov/issue/implementing-sbar-across-large-multihospital-health-system…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41110/psn-pdf
    January 18, 2013 - Applying aviation factors to oral and maxillofacial surgery—the human element. January 18, 2013 Seager L, Smith DW, Patel A, et al. Applying aviation factors to oral and maxillofacial surgery--the human element. Br J Oral Maxillofac Surg. 2013;51(1):8-13. doi:10.1016/j.bjoms.2011.11.024. https://psnet.ahrq.gov/iss…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40440/psn-pdf
    July 02, 2014 - Residents' reflections on quality improvement: temporal stability and associations with preventability of adverse patient events. July 2, 2014 Wittich CM, Reed DA, Drefahl MM, et al. Residents' reflections on quality improvement: temporal stability and associations with preventability of adverse patient events. Ac…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43181/psn-pdf
    May 14, 2014 - Overextended: fighting the fatigue of long shifts. May 14, 2014 Douglass JA. Overextended: Fighting the fatigue of long shifts. Nursing (Brux). 2014;44(3):67-8. doi:10.1097/01.NURSE.0000441895.42899.0c. https://psnet.ahrq.gov/issue/overextended-fighting-fatigue-long-shifts Many studies have demonstrated the link b…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72537/psn-pdf
    December 02, 2020 - Automation failures and patient safety. December 2, 2020 Ruskin KJ, Ruskin AC, O’Connor M. Automation failures and patient safety. Curr Opin Anaesthesiol. 2020;33(6):788-792. doi:10.1097/aco.0000000000000935. https://psnet.ahrq.gov/issue/automation-failures-and-patient-safety Task automation in medicine is a core …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44144/psn-pdf
    May 27, 2015 - Maintaining safety in the dialysis facility. May 27, 2015 Kliger AS. Maintaining safety in the dialysis facility. Clin J Am Soc Nephrol. 2015;10(4):688-95. doi:10.2215/CJN.08960914. https://psnet.ahrq.gov/issue/maintaining-safety-dialysis-facility Failure to consider human factors and poor communication can contri…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35282/psn-pdf
    May 27, 2011 - Comprehensive analysis of a medication dosing error related to CPOE. May 27, 2011 Horsky J, Kuperman GJ, Patel VL. Comprehensive Analysis of a Medication Dosing Error Related to CPOE: Table 1. J Am Med Info Assoc. 2005;12(4). doi:10.1197/jamia.m1740. https://psnet.ahrq.gov/issue/comprehensive-analysis-medication-d…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42901/psn-pdf
    January 29, 2014 - Do safety checklists improve teamwork and communication in the operating room? A systematic review. January 29, 2014 Russ S, Rout S, Sevdalis N, et al. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg. 2013;258(6):856-71. doi:10.1097/SLA.0000000000000206…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50781/psn-pdf
    January 08, 2020 - Harnessing the power of medical malpractice data to improve patient care. January 8, 2020 Siegal D, Swift J, Forget J, et al. Harnessing the power of medical malpractice data to improve patient care. J Healthc Risk Manag. 2020;39(3):28-36. doi:10.1002/jhrm.21393. https://psnet.ahrq.gov/issue/harnessing-power-medic…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845080/psn-pdf
    February 22, 2023 - A high-reliability organization mindset. February 22, 2023 Merchant NB, O’Neal J, Dealino-Perez C, et al. A high-reliability organization mindset. Am J Med Qual. 2022;37(6):504-510. doi:10.1097/jmq.0000000000000086. https://psnet.ahrq.gov/issue/high-reliability-organization-mindset The goal for health care organiz…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43529/psn-pdf
    October 01, 2014 - National pediatric anesthesia safety quality improvement program in the United States. October 1, 2014 Kurth D, Tyler D, Heitmiller ES, et al. National pediatric anesthesia safety quality improvement program in the United States. Anesth Analg. 2014;119(1):112-21. doi:10.1213/ANE.0000000000000040. https://psnet.ahr…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42506/psn-pdf
    August 28, 2013 - Foundations for teaching surgeons to address the contributions of systems to operating room team conflict. August 28, 2013 Rogers DA, Lingard LA, Boehler ML, et al. Foundations for teaching surgeons to address the contributions of systems to operating room team conflict. Am J Surg. 2013;206(3):428-32. doi:10.1016/…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46363/psn-pdf
    December 13, 2017 - Exploring how nursing schools handle student errors and near misses. December 13, 2017 Disch J, Barnsteiner J, Connor S, et al. CE: Original Research: Exploring How Nursing Schools Handle Student Errors and Near Misses. Am J Nurs. 2017;117(10):24-31. doi:10.1097/01.NAJ.0000525849.35536.74. https://psnet.ahrq.gov/…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45071/psn-pdf
    April 27, 2016 - Using simulation to identify sources of medical diagnostic error in child physical abuse. April 27, 2016 Anderst J, Nielsen-Parker M, Moffatt M, et al. Using simulation to identify sources of medical diagnostic error in child physical abuse. Child Abuse Negl. 2016;52:62-69. doi:10.1016/j.chiabu.2015.12.015. https:…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47978/psn-pdf
    May 01, 2019 - Patient Safety. May 1, 2019 GMS J Med Educ. 2019;36:Doc11-Doc22. https://psnet.ahrq.gov/issue/patient-safety-16 Patient safety has been described as an unmet need in physician training. This special issue covers areas of focus for a patient safety curriculum drawn from experience in the German medical education sy…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36225/psn-pdf
    July 10, 2008 - Transfers of patient care between house staff on internal medicine wards: a national survey. July 10, 2008 Horwitz LI, Krumholz HM, Green M, et al. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173-7. https://psnet.ahrq.gov/issue/transfe…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37847/psn-pdf
    June 18, 2008 - Effect of the 80-hour work week on resident case coverage. June 18, 2008 Shin S, Britt R, Britt LD. Effect of the 80-hour work week on resident case coverage. J Am Coll Surg. 2008;206(5):798-800; discussion 801-3. doi:10.1016/j.jamcollsurg.2007.12.028. https://psnet.ahrq.gov/issue/effect-80-hour-work-week-resident…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44139/psn-pdf
    June 10, 2015 - In situ simulated cardiac arrest exercises to detect system vulnerabilities. June 10, 2015 Barbeito A, Bonifacio AS, Holtschneider M, et al. In situ simulated cardiac arrest exercises to detect system vulnerabilities. Simul Healthc. 2015;10(3):154-62. doi:10.1097/SIH.0000000000000087. https://psnet.ahrq.gov/issue/…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42109/psn-pdf
    March 13, 2013 - Nursing crew resource management: a follow-up report from the Veterans Health Administration. March 13, 2013 Sculli GL, Fore AM, West P, et al. Nursing crew resource management: a follow-up report from the Veterans Health Administration. J Nurs Adm. 2013;43(3):122-6. doi:10.1097/NNA.0b013e318283dafa. https://psnet…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836971/psn-pdf
    April 20, 2022 - Patients should know who's operating, surgeons say. April 20, 2022 Laber-Warren E. MedPage Today. April 5, 2022. https://psnet.ahrq.gov/issue/patients-should-know-whos-operating-surgeons-say Resident autonomy is an essential component to medical training, but it is not without patient safety risks. This news artic…