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  1. FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. | PSNet

    psnet.ahrq.gov/issue/fda-safety-communication-flexible-bronchoscopes-and-updated-recommendations-reprocessing
    March 11, 2015 - Press Release/Announcement FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. Citation Text: FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. Silver Springs, MD: US Food and Drug Administration: Jun…

  2. FDA’s promised guidance on pulse oximeters unlikely to end decades of racial bias. | PSNet

    psnet.ahrq.gov/issue/fdas-promised-guidance-pulse-oximeters-unlikely-end-decades-racial-bias
    November 06, 2024 - Newspaper/Magazine Article FDA’s promised guidance on pulse oximeters unlikely to end decades of racial bias. Citation Text: Allen A. FDA’s promised guidance on pulse oximeters unlikely to end decades of racial bias. KFF Health News. October 07, 2024; Copy Citation Format: …

  3. What can we learn from coroners’ reports on preventable deaths? | PSNet

    psnet.ahrq.gov/issue/what-can-we-learn-coroners-reports-preventable-deaths
    October 28, 2020 - Commentary What can we learn from coroners’ reports on preventable deaths? Citation Text: Jeraj S. What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

  4. ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. | PSNet

    psnet.ahrq.gov/issue/ashp-guidelines-preventing-medication-errors-chemotherapy-and-biotherapy
    September 07, 2016 - Organizational Policy/Guidelines ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. Citation Text: Goldspiel B, Hoffman JM, Griffith NL, et al. ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. Am J Health Syst Pharm. 2015;72…

  5. Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. | PSNet

    psnet.ahrq.gov/issue/human-cognition-and-dynamics-failure-rescue-lewis-blackman-case
    April 24, 2018 - Commentary Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. Citation Text: Acquaviva K, Haskell H, Johnson J. Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. J Prof Nurs. 2013;29(2):95-101. doi:10.1016/j.profnurs.2012.12.009.…

  6. Presenting complaint: use of language that disempowers patients. | PSNet

    psnet.ahrq.gov/issue/presenting-complaint-use-language-disempowers-patients
    July 13, 2022 - Commentary Presenting complaint: use of language that disempowers patients. Citation Text: doi:10.1136/bmj-2021-066720. Copy Citation Format: DOI BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Save Save to …

  7. Teaching about how doctors think: a longitudinal curriculum in cognitive bias and diagnostic error for residents. | PSNet

    psnet.ahrq.gov/issue/teaching-about-how-doctors-think-longitudinal-curriculum-cognitive-bias-and-diagnostic-error
    July 02, 2014 - Study Teaching about how doctors think: a longitudinal curriculum in cognitive bias and diagnostic error for residents. Citation Text: Reilly JB, Ogdie AR, Von Feldt JM, et al. Teaching about how doctors think: a longitudinal curriculum in cognitive bias and diagnostic error for reside…

  8. Notes on healing after a missed diagnosis. | PSNet

    psnet.ahrq.gov/issue/notes-healing-after-missed-diagnosis
    May 18, 2022 - Commentary Notes on healing after a missed diagnosis. Citation Text: Fleming EA. Notes on healing after a missed diagnosis. JAMA. 2022;328(13):1297-1298. doi:10.1001/jama.2022.15724. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

  9. Issues and complexities in safety culture assessment in healthcare. | PSNet

    psnet.ahrq.gov/issue/issues-and-complexities-safety-culture-assessment-healthcare
    October 09, 2024 - Commentary Issues and complexities in safety culture assessment in healthcare. Citation Text: Ellis LA, Falkland E, Hibbert P, et al. Issues and complexities in safety culture assessment in healthcare. Front Public Health. 2023;11:1217542. doi:10.3389/fpubh.2023.1217542. Copy Citation …

  10. Work interruptions and their contribution to medication administration errors: an evidence review. | PSNet

    psnet.ahrq.gov/issue/work-interruptions-and-their-contribution-medication-administration-errors-evidence-review
    July 22, 2020 - Review Work interruptions and their contribution to medication administration errors: an evidence review. Citation Text: Biron AD, Loiselle CG, Lavoie-Tremblay M. Work interruptions and their contribution to medication administration errors: an evidence review. Worldviews Evid Based Nurs…

  11. Can teamwork promote safety in organizations? | PSNet

    psnet.ahrq.gov/issue/can-teamwork-promote-safety-organizations
    April 24, 2019 - Review Emerging Classic Can teamwork promote safety in organizations? Citation Text: Salas E, Bisbey TM, Traylor AM, et al. Can teamwork promote safety in organizations? . Ann Rev Org Psychol Org Behav. 2020;7(1):283-313. doi:10.1146/annurev-orgpsych-012119-0454…

  12. Second-victim phenomenon. | PSNet

    psnet.ahrq.gov/issue/second-victim-phenomenon
    July 10, 2024 - Review Second-victim phenomenon. Citation Text: New L, Lambeth T. Second-victim phenomenon. Nurs Clin North Am. 2024;59(1):141-152. doi:10.1016/j.cnur.2023.11.011. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  13. Learning mechanisms to limit medication administration errors. | PSNet

    psnet.ahrq.gov/issue/learning-mechanisms-limit-medication-administration-errors
    August 30, 2017 - Study Learning mechanisms to limit medication administration errors. Citation Text: Drach-Zahavy A, Pud D. Learning mechanisms to limit medication administration errors. J Adv Nurs. 2010;66(4). doi:10.1111/j.1365-2648.2010.05294.x. Copy Citation Format: DOI Google Scholar …

  14. Attitudes of health sciences faculty members towards interprofessional teamwork and education. | PSNet

    psnet.ahrq.gov/issue/attitudes-health-sciences-faculty-members-towards-interprofessional-teamwork-and-education
    March 02, 2011 - Study Attitudes of health sciences faculty members towards interprofessional teamwork and education. Citation Text: Curran VR, Sharpe D, Forristall J. Attitudes of health sciences faculty members towards interprofessional teamwork and education. Med Educ. 2007;41(9):892-896. Copy Cit…

  15. The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff. | PSNet

    psnet.ahrq.gov/issue/power-collaboration-patient-safety-programs-building-safe-passage-patients-nurses-and
    April 21, 2021 - Commentary The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff. Citation Text: Kerfoot KM, Rapala K, Ebright PR, et al. The power of collaboration with patient safety programs: building safe passage for patients, nurse…

  16. Development and validation of a tool to improve paediatric referral/consultation communication. | PSNet

    psnet.ahrq.gov/issue/development-and-validation-tool-improve-paediatric-referralconsultation-communication
    May 25, 2011 - Study Development and validation of a tool to improve paediatric referral/consultation communication. Citation Text: Stille CJ, Mazor KM, Meterko V, et al. Development and validation of a tool to improve paediatric referral/consultation communication. BMJ Qual Saf. 2011;20(8):692-7. do…

  17. Advancing a More Health-Literate Approach to Patient Safety | PSNet

    psnet.ahrq.gov/issue/advancing-more-health-literate-approach-patient-safety
    May 31, 2017 - Journal Article Advancing a More Health-Literate Approach to Patient Safety Citation Text: Sanders LM. Advancing a More Health-Literate Approach to Patient Safety. J Pediatr. 2019;214:10-11. doi:10.1016/j.jpeds.2019.07.003. Copy Citation Format: DOI Google Scholar PubMed Bi…

  18. ReCASTing the RCA: an improved model for performing root cause analyses. | PSNet

    psnet.ahrq.gov/issue/recasting-rca-improved-model-performing-root-cause-analyses
    November 10, 2010 - Commentary ReCASTing the RCA: an improved model for performing root cause analyses. Citation Text: Pham JC, Kim GR, Natterman JP, et al. ReCASTing the RCA: An Improved Model for Performing Root Cause Analyses. American Journal of Medical Quality. 2010;25(3). doi:10.1177/1062860609359533…

  19. Beyond "see one, do one, teach one": toward a different training paradigm. | PSNet

    psnet.ahrq.gov/issue/beyond-see-one-do-one-teach-one-toward-different-training-paradigm
    March 01, 2011 - Commentary Beyond "see one, do one, teach one": toward a different training paradigm. Citation Text: Rodriguez-Paz JM, Kennedy M, Salas E, et al. Beyond "see one, do one, teach one": toward a different training paradigm. Qual Saf Health Care. 2009;18(1):63-8. doi:10.1136/qshc.2007.02…

  20. Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System. | PSNet

    psnet.ahrq.gov/issue/case-study-getting-boards-board-allen-memorial-hospital-iowa-health-system
    August 04, 2021 - Commentary Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System. Citation Text: Slessor SR, Crandall JB, Nielsen GA. Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System. Jt Comm J Qual Patient Saf. 2008;34(4):221-227. Copy …
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