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psnet.ahrq.gov/issue/adverse-events-rehabilitation-hospitals-national-incidence-among-medicare-beneficiaries
January 09, 2019 - Book/Report
Classic
Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.
Citation Text:
Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. Levinson DR. Washington, DC: US Departmen…
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psnet.ahrq.gov/issue/using-human-factors-methods-mitigate-bias-artificial-intelligence-based-clinical-decision
July 10, 2019 - Commentary
Using human factors methods to mitigate bias in artificial intelligence-based clinical decision support.
Citation Text:
Militello LG, Diiulio J, Wilson DL, et al. Using human factors methods to mitigate bias in artificial intelligence-based clinical decision support. J Am Med …
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psnet.ahrq.gov/issue/barriers-and-enhancers-trust-just-culture-hospital-settings-systematic-review
February 02, 2022 - Review
The barriers and enhancers to trust in a just culture in hospital settings: a systematic review.
Citation Text:
van Marum S, Verhoeven D, de Rooy D. The barriers and enhancers to trust in a just culture in hospital settings: a systematic review. J Patient Saf. 2022;18(7):e1067-e10…
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psnet.ahrq.gov/issue/interprofessional-clinical-event-debriefing-does-it-make-difference-attitudes-emergency
April 06, 2022 - Study
Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings.
Citation Text:
Rose SC, Ashari NA, Davies JM, et al. Interprofessional clinical event debriefing-does it make a difference? At…
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digital.ahrq.gov/health-care-theme/clinical-decision-making
January 01, 2023 - Clinical Decision Making
Artificial Intelligence and Human Factors in Healthcare Quality & Safety
Description
Using a conference model, this study convenes a multidisciplinary group of experts to explore the integration of human factors engineering approaches in the implementa…
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digital.ahrq.gov/program-overview/research-stories/use-artificial-intelligence-and-machine-learning-improve-care
January 01, 2023 - Use of Artificial Intelligence and Machine Learning to Improve Care by Critical Care Pharmacists
Theme:
Supporting Health Systems in Advancing Care Delivery
Subtheme:
Using Digital Healthcare Tools to Improve Patient Safety
Using machine learning- and artificial intelligence-developed tool…
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psnet.ahrq.gov/issue/integrating-incident-data-five-reporting-systems-assess-patient-safety-making-sense-elephant
November 25, 2009 - Study
Classic
Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant.
Citation Text:
Levtzion-Korach O, Frankel A, Alcalai H, et al. Integrating incident data from five reporting systems to assess patient saf…
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/monitor-patient-outcomes
August 01, 2025 - An official website of the Department of Health & Human Services
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psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room
November 21, 2011 - Study
Incorrect surgical procedures within and outside of the operating room.
Citation Text:
Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-34. doi:10.1001/archsurg.2009.126.
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psnet.ahrq.gov/issue/impact-diagnostic-decision-support-system-consultation-perceptions-gps-and-patients
June 28, 2017 - Study
The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients.
Citation Text:
Porat T, Delaney B, Kostopoulou O. The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients. BMC Med Inform Decis M…
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psnet.ahrq.gov/issue/structured-approach-ehr-surveillance-diagnostic-error-acute-care-exploratory-analysis-two
October 16, 2024 - Study
A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.
Citation Text:
Malik MA, Motta-Calderon D, Piniella N, et al. A structured approach to EHR surveillance of diagnostic error in acute car…
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psnet.ahrq.gov/issue/differences-between-methods-detecting-medication-errors-secondary-analysis-medication
December 18, 2019 - Study
Emerging Classic
Differences between methods of detecting medication errors: a secondary analysis of medication administration errors using incident reports, the Global Trigger Tool method, and observations.
Citation Text:
Härkänen M, Turunen H, Vehviläine…
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psnet.ahrq.gov/issue/reduction-race-and-gender-bias-clinical-treatment-recommendations-using-clinician-peer
August 09, 2023 - Study
The reduction of race and gender bias in clinical treatment recommendations using clinician peer networks in an experimental setting.
Citation Text:
Centola D, Guilbeault D, Sarkar U, et al. The reduction of race and gender bias in clinical treatment recommendations using clinician…
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psnet.ahrq.gov/issue/lessons-learned-implementing-complex-and-innovative-patient-safety-learning-laboratory
August 03, 2022 - Study
Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center
Citation Text:
Businger AC, Fuller TE, Schnipper JL, et al. Lessons learned implementing a complex and innovative patient safety learning laboratory p…
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psnet.ahrq.gov/issue/cross-sectional-observational-study-high-override-rates-drug-allergy-alerts-inpatient-and
July 02, 2019 - Study
A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outpatient settings, and opportunities for improvement.
Citation Text:
Slight SP, Beeler PE, Seger DL, et al. A cross-sectional observational study of high override rates of drug al…
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/WhatIsWorkflow.ppt
January 01, 2009 - How Do I Evaluate Workflow?
What is Workflow?
Defining workflow
Definitions of workflow vary. Here are a couple:
The flow of work through space and time, where work is comprised of three components: inputs are transformed into outputs.[1]
The activities, tools, and processes needed to produce or modify work, pr…
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psnet.ahrq.gov/issue/contribution-staffing-medication-administration-errors-text-mining-analysis-incident-report
December 21, 2022 - Study
The contribution of staffing to medication administration errors: a text mining analysis of incident report data.
Citation Text:
Härkänen M, Vehviläinen‐Julkunen K, Murrells T, et al. The Contribution of Staffing to Medication Administration Errors: A Text Mining Analysis of Incide…
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psnet.ahrq.gov/issue/notification-abnormal-lab-test-results-electronic-medical-record-do-any-safety-concerns
April 04, 2011 - Study
Classic
Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?
Citation Text:
Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safet…
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psnet.ahrq.gov/issue/analysis-electronic-health-record-related-patient-safety-concerns
January 21, 2019 - Study
Classic
An analysis of electronic health record–related patient safety concerns.
Citation Text:
Meeks DW, Smith MW, Taylor L, et al. An analysis of electronic health record-related patient safety concerns. J Am Med Inform Assoc. 2014;21(6):1053-9. doi:10.1…
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psnet.ahrq.gov/issue/root-cause-analysis-using-prevention-and-recovery-information-system-monitoring-and-analysis
May 18, 2022 - Review
Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review.
Citation Text:
Driesen BEJM, Baartmans M, Merten H, et al. Root cause analysis using the prevention and recovery in…