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psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure
September 07, 2022 - Audiovisual Presentation
First, Do No Harm Part 1: A Case Study of Systems Failure.
Citation Text:
First, Do No Harm Part 1: A Case Study of Systems Failure. Chicago: Partnership for Patient Safety, Harvard Risk Management Foundation; 2000.
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psnet.ahrq.gov/issue/teamstepps-master-training-course
June 08, 2022 - International Meeting/Conference
TeamSTEPPS Master Training Virtual Course.
Citation Text:
TeamSTEPPS Master Training Virtual Course. AHA Team Training. September 19 - November 7, 2024.
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psnet.ahrq.gov/issue/where-medical-errors-occur-and-how-avoid-them
September 22, 2010 - Government Resource
Where Medical Errors Occur and How to Avoid Them.
Citation Text:
Where Medical Errors Occur and How to Avoid Them. Clancy C. Navigating the Health Care System. Rockville, MD: Agency for Healthcare Research and Quality; May 2010.
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psnet.ahrq.gov/issue/when-things-go-wrong-voices-patients-and-families
November 19, 2015 - Audiovisual
When Things Go Wrong: Voices of Patients and Families.
Citation Text:
When Things Go Wrong: Voices of Patients and Families. CRICO/RMF; Harvard Risk Management Foundation
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psnet.ahrq.gov/issue/removing-insult-injury-disclosing-adverse-events
November 07, 2012 - Audiovisual
Removing Insult from Injury: Disclosing Adverse Events.
Citation Text:
Removing Insult from Injury: Disclosing Adverse Events. Johns Hopkins Bloomberg School of Public Health
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psnet.ahrq.gov/issue/10-medical-errors-changed-standard-care
December 19, 2016 - Image/Poster
10 medical errors that changed the standard of care.
Citation Text:
10 medical errors that changed the standard of care. Bialek BB. Medscape Today. January 18, 2012.
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psnet.ahrq.gov/node/33848/psn-pdf
December 01, 2017 - outcomes were tightly correlated with surgical technique (as judged
by peer reviews of intraoperative videos
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psnet.ahrq.gov/issue/selective-attention-task
August 11, 2010 - Audiovisual
Classic
The Selective Attention Task.
Citation Text:
The Selective Attention Task. Simons DJ. Visual Cognition Lab. Champaign, IL: University of Illinois; 2010.
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psnet.ahrq.gov/issue/prevalence-adverse-drug-combinations-large-post-mortem-toxicology-database
July 29, 2020 - Study
Prevalence of adverse drug combinations in a large post-mortem toxicology database.
Citation Text:
Launiainen T, Vuori E, Ojanperä I. Prevalence of adverse drug combinations in a large post-mortem toxicology database. Int J Legal Med. 2009;123(2):109-15. doi:10.1007/s00414-008-02…
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psnet.ahrq.gov/issue/learning-adverse-events-and-near-misses
January 15, 2020 - Commentary
Learning from adverse events and near misses.
Citation Text:
Greenberg CC. Learning from adverse events and near misses. J Gastrointest Surg. 2009;13(1):3-5. doi:10.1007/s11605-008-0693-6.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/issue/refining-framework-enhance-communication-emergency-department-during-diagnostic-process
May 08, 2024 - Study
Refining a framework to enhance communication in the emergency department during the diagnostic process: an eDelphi approach.
Citation Text:
Manojlovich M, Bettencourt AP, Mangus CW, et al. Refining a framework to enhance communication in the emergency department during the diagnos…
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psnet.ahrq.gov/innovations-video
Learn About the Submit an Innovation Process
PSNet’s Submit an Innovation feature allows organizations to share successfully implemented innovative practices and/or interventions that have resulted in improved patient safety and reduced harm. Watch the video below to learn more about the Submit an Innovation process…
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psnet.ahrq.gov/submit-case
The Submit a Case Process
PSNet’s Submit a Case feature allows health care professionals to submit de-identified cases that feature patient safety and health care quality issues to PSNet’s WebM&M educational journal. Watch the video below to learn more about the Submit a Case process.
Submit Your Case
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psnet.ahrq.gov/issue/surgical-adverse-events-systematic-review
June 01, 2012 - Review
Surgical adverse events: a systematic review.
Citation Text:
Anderson O, Davis R, Hanna GB, et al. Surgical adverse events: a systematic review. Am J Surg. 2013;206(2):253-62. doi:10.1016/j.amjsurg.2012.11.009.
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psnet.ahrq.gov/issue/what-whiteboards-trauma-center-operating-suite-can-teach-us-about-emergency-department
August 29, 2011 - Study
What whiteboards in a trauma center operating suite can teach us about emergency department communication.
Citation Text:
Xiao Y, Schenkel SM, Faraj S, et al. What whiteboards in a trauma center operating suite can teach us about emergency department communication. Ann Emerg Med.…
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psnet.ahrq.gov/node/854642/psn-pdf
October 18, 2023 - Cybersecurity for the Clinician.
October 18, 2023
Chicago, IL: American Medical Association; 2023.
https://psnet.ahrq.gov/issue/cybersecurity-clinician
The vulnerability of healthcare information technologies and devices to malicious interruptions is
increasingly recognized as a patient safety hazard. This eight-e…
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psnet.ahrq.gov/issue/explainable-artificial-intelligence-safe-intraoperative-decision-support
October 13, 2015 - Commentary
Explainable artificial intelligence for safe intraoperative decision support.
Citation Text:
Gordon L, Grantcharov T, Rudzicz F. Explainable Artificial Intelligence for Safe Intraoperative Decision Support. JAMA Surg. 2019. doi:10.1001/jamasurg.2019.2821.
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psnet.ahrq.gov/issue/telemedicine-vs-telephone-consultations-and-medication-prescribing-errors-among-referring
September 23, 2020 - Study
Telemedicine vs telephone consultations and medication prescribing errors among referring physicians: a cluster randomized crossover trial.
Citation Text:
Marcin JP, Lieng MK, Mouzoon J, et al. Telemedicine vs telephone consultations and medication prescribing errors among referrin…
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psnet.ahrq.gov/node/41655/psn-pdf
February 01, 2015 - Do No Harm: Jess's Story.
February 1, 2015
Barnett T, Barnett P.
https://psnet.ahrq.gov/issue/project-jessica
This video chronicles how an undiagnosed heart condition led to a teenager's death and offers tips for
patients to prevent medical errors.
https://psnet.ahrq.gov/issue/project-jessica
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/847732/psn-pdf
April 19, 2023 - Saving Moms.
April 19, 2023
Boswell B. KCET: April 2023.
https://psnet.ahrq.gov/issue/saving-moms
Increasing attention is being placed on addressing inequities in maternal health care. This video shares
stories of mothers experiencing harm during pregnancy and steps being taken to minimize the impact of
implicit …