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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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psnet.ahrq.gov/node/73456/psn-pdf
June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult
Intubation and Severe Hypoxemia
June 30, 2021
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…
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psnet.ahrq.gov/node/836862/psn-pdf
April 06, 2022 - What are we missing? The quality of intraoperative
handover before and after introduction of a checklist.
April 6, 2022
Lane S, Gross M, Arzola C, et al. What are we missing? The quality of intraoperative handover before and
after introduction of a checklist. Can J Anaesth. 2022;69(7):832-840. doi:10.1007/s12630-02…
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psnet.ahrq.gov/node/47438/psn-pdf
June 02, 2019 - Developing an intervention to reduce harm in hospitalized
patients: patients and families in research.
June 2, 2019
Schenk EC, Bryant RA, Van Son CR, et al. Developing an Intervention to Reduce Harm in Hospitalized
Patients: Patients and Families in Research. J Nurs Care Qual. 2019;34(3):273-278.
doi:10.1097/NCQ.0…
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psnet.ahrq.gov/node/846147/psn-pdf
March 15, 2023 - Automated capture of intraoperative adverse events using
artificial intelligence: a systematic review and meta-
analysis.
March 15, 2023
Eppler MB, Sayegh AS, Maas M, et al. Automated capture of intraoperative adverse events using artificial
intelligence: a systematic review and meta-analysis. J Clin Med. 2023;12(…
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psnet.ahrq.gov/node/44695/psn-pdf
June 07, 2016 - Enhancing surgical safety using digital multimedia
technology.
June 7, 2016
Dixon JL, Mukhopadhyay D, Hunt J, et al. Enhancing surgical safety using digital multimedia technology.
Am J Surg. 2016;211(6):1095-8. doi:10.1016/j.amjsurg.2015.08.023.
https://psnet.ahrq.gov/issue/enhancing-surgical-safety-using-digital-…
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psnet.ahrq.gov/node/46241/psn-pdf
January 30, 2018 - Interventions to improve oral chemotherapy safety and
quality: a systematic review.
January 30, 2018
Zerillo JA, Goldenberg BA, Kotecha RR, et al. Interventions to Improve Oral Chemotherapy Safety and
Quality. JAMA Oncol. 2017;4(1):105-117. doi:10.1001/jamaoncol.2017.0625.
https://psnet.ahrq.gov/issue/intervention…
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psnet.ahrq.gov/issue/preventing-medical-errors
May 03, 2006 - Government Resource
Preventing Medical Errors.
Citation Text:
Food and Drug Administration; FDA.
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September 10, 2008
Food and Drug Ad…
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psnet.ahrq.gov/issue/preventing-dosage-errors-diastat-acudial
March 14, 2007 - Audiovisual
Preventing dosage errors with Diastat AcuDial.
Citation Text:
Food and Drug Administration; FDA
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January 17, 2007
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psnet.ahrq.gov/issue/teamstepps-health-care-risk-managers-improving-teamwork-and-communication
March 27, 2019 - September 20, 2023
Videos of simulated after action reviews: a training resource to support
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psnet.ahrq.gov/node/73624/psn-pdf
August 25, 2021 - System factors affecting patient safety in the OR: an
analysis of safety threats and resiliency.
August 25, 2021
Adams-McGavin RC, Jung JJ, van Dalen ASHM, et al. System factors affecting patient safety in the OR: an
analysis of safety threats and resiliency. Ann Surg. 2021;274(1):114-119.
doi:10.1097/sla.00000000…
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psnet.ahrq.gov/node/72797/psn-pdf
March 03, 2021 - Evaluating the impact of a pharmacist-led prescribing
feedback intervention on prescribing errors in a hospital
setting.
March 3, 2021
Lloyd M, Watmough SD, O'Brien SV, et al. Evaluating the impact of a pharmacist-led prescribing feedback
intervention on prescribing errors in a hospital setting. Res Social Adm Pha…
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psnet.ahrq.gov/node/42839/psn-pdf
January 09, 2014 - Teaching medical error disclosure to residents using
patient-centered simulation training.
January 9, 2014
Sukalich S, Elliott JO, Ruffner G. Teaching medical error disclosure to residents using patient-centered
simulation training. Acad Med. 2014;89(1):136-43. doi:10.1097/ACM.0000000000000046.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/44784/psn-pdf
May 03, 2017 - WISH Patient Safety Forum
May 3, 2017
World Innovation Summit for Health 2015. Doha, Qatar: Qatar Foundation; February 2015.
https://psnet.ahrq.gov/issue/wish-patient-safety-forum
The 2015 conference focused on persisting barriers to patient safety worldwide and recommended
strategies to achieve lasting improvemen…
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psnet.ahrq.gov/node/44190/psn-pdf
June 03, 2015 - Minimizing medical mistakes: mother's mission to reduce
hospital errors.
June 3, 2015
Takahara D. KDVR. May 19, 2015.
https://psnet.ahrq.gov/issue/minimizing-medical-mistakes-mothers-mission-reduce-hospital-errors
Parents of children who experience harm in the course of medical care serve as advocates to drive saf…
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psnet.ahrq.gov/node/43177/psn-pdf
May 14, 2014 - Disclosing medical errors to patients: effects of nonverbal
involvement.
May 14, 2014
Hannawa AF. Disclosing medical errors to patients: effects of nonverbal involvement. Patient Educ Couns.
2014;94(3):310-313. doi:10.1016/j.pec.2013.11.007.
https://psnet.ahrq.gov/issue/disclosing-medical-errors-patients-effects-n…
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psnet.ahrq.gov/node/43249/psn-pdf
June 18, 2014 - Automated and electronically assisted hand hygiene
monitoring systems: a systematic review.
June 18, 2014
Ward MA, Schweizer ML, Polgreen PM, et al. Automated and electronically assisted hand hygiene
monitoring systems: a systematic review. Am J Infect Control. 2014;42(5):472-8.
doi:10.1016/j.ajic.2014.01.002.
ht…
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psnet.ahrq.gov/node/39407/psn-pdf
March 31, 2010 - What ring tone should be used for patient safety? Early
results with a Blackberry-based telementoring safety
solution.
March 31, 2010
Parker A, Rubinfeld IS, Azuh O, et al. What ring tone should be used for patient safety? Early results with a
Blackberry-based telementoring safety solution. Am J Surg. 2010;199(3):…
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psnet.ahrq.gov/node/41534/psn-pdf
July 25, 2012 - Protecting patients from an unsafe system: the etiology
and recovery of intraoperative deviations in care.
July 25, 2012
Hu Y-Y, Arriaga AF, Roth EM, et al. Protecting patients from an unsafe system: the etiology and recovery
of intraoperative deviations in care. Ann Surg. 2012;256(2):203-10. doi:10.1097/SLA.0b013e…
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psnet.ahrq.gov/node/38970/psn-pdf
July 05, 2013 - Joint Commission Center for Transforming Healthcare.
July 5, 2013
Joint Commission.
https://psnet.ahrq.gov/issue/joint-commission-center-transforming-healthcare
The Joint Commission has traditionally focused on accreditation of health care organizations and, through
its Joint Commission Resources arm, on quality i…