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psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm
June 21, 2016 - Book/Report
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.
Citation Text:
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015.
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psnet.ahrq.gov/issue/technical-mistakes-during-acquisition-electrocardiogram
March 09, 2022 - Review
Technical mistakes during the acquisition of the electrocardiogram.
Citation Text:
García-Niebla J, Llontop-García P, Valle-Racero JI, et al. Technical mistakes during the acquisition of the electrocardiogram. Ann Noninvasive Electrocardiol. 2009;14(4):389-403. doi:10.1111/j.154…
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psnet.ahrq.gov/issue/how-can-we-make-diagnosis-safer
April 12, 2014 - Commentary
How can we make diagnosis safer?
Citation Text:
Schiff G, Leape L. Commentary: how can we make diagnosis safer? Acad Med. 2012;87(2):135-138. doi:10.1097/ACM.0b013e31823f711c.
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psnet.ahrq.gov/issue/do-no-harm-and-most-good-ai-health-care
March 19, 2019 - Commentary
To do no harm - and the most good - with AI in health care.
Citation Text:
Goldberg CB, Adams L, Blumenthal D, et al. To do no harm - and the most good - with AI in health care. NEJM AI. 2024;1(3). doi:10.1056/aip2400036.
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psnet.ahrq.gov/issue/framing-diagnostic-error-epidemiological-perspective
January 12, 2022 - Review
Framing diagnostic error: an epidemiological perspective.
Citation Text:
Hunter MK, Singareddy C, Mundt KA. Framing diagnostic error: an epidemiological perspective. Front Public Health. 2024;12:1479750. doi:10.3389/fpubh.2024.1479750.
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psnet.ahrq.gov/issue/governing-safety-artificial-intelligence-healthcare
February 28, 2024 - Review
Emerging Classic
Governing the safety of artificial intelligence in healthcare.
Citation Text:
Macrae C. Governing the safety of artificial intelligence in healthcare. BMJ Qual Saf. 2019;28(6):495-498. doi:10.1136/bmjqs-2019-009484.
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psnet.ahrq.gov/issue/what-accountability-health-care
April 19, 2013 - Commentary
Classic
What is accountability in health care?
Citation Text:
Emanuel EJ, Emanuel LL. What is accountability in health care? Ann Intern Med. 1996;124(2):229-239.
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psnet.ahrq.gov/issue/support-methods-healthcare-professionals-who-are-second-victims-integrative-review
April 27, 2022 - Review
Support methods for healthcare professionals who are second victims: an integrative review.
Citation Text:
Support methods for healthcare professionals who are second victims: an integrative review. Neft MW, Sekula K, Zoucha R, et al. AANA J. 2022;90(3):189-196.
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psnet.ahrq.gov/issue/intravenous-infusion-safety-technology-return-investment
October 29, 2017 - Study
Intravenous infusion safety technology: return on investment.
Citation Text:
Danello SH, Maddox RR, Schaack GJ. Intravenous Infusion Safety Technology: Return on Investment. Hosp Pharm. 2010;44(8):680-688. doi:10.1310/hpj4408-680.
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psnet.ahrq.gov/issue/medical-problem-solving-analysis-clinical-reasoning
July 18, 2018 - Book/Report
Classic
Medical Problem Solving: An Analysis of Clinical Reasoning.
Citation Text:
Medical Problem Solving: An Analysis of Clinical Reasoning. Elstein AS, ed. Cambridge, MA: Harvard University Press; 1978. ISBN: 9780674561250.
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psnet.ahrq.gov/issue/enhancing-effectiveness-team-debriefings-medical-simulation-more-best-practices
March 17, 2021 - Commentary
Enhancing the effectiveness of team debriefings in medical simulation: more best practices.
Citation Text:
Lyons R, Lazzara EH, Benishek LE, et al. Enhancing the effectiveness of team debriefings in medical simulation: more best practices. Jt Comm J Qual Patient Saf. 2015;41(3…
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psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
October 03, 2012 - Commentary
Improving patient care. The cognitive psychology of missed diagnoses.
Citation Text:
Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142(2):115-120.
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psnet.ahrq.gov/issue/deprescribing-clinical-improvement-focus
April 08, 2011 - Study
Deprescribing as a clinical improvement focus.
Citation Text:
Dharmarajan TS, Choi H, Hossain N, et al. Deprescribing as a Clinical Improvement Focus. J Am Med Dir Assoc. 2020;21(3):355-360. doi:10.1016/j.jamda.2019.08.031.
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psnet.ahrq.gov/issue/amid-lack-accountability-bias-maternity-care-california-family-seeks-justice
September 06, 2023 - Newspaper/Magazine Article
Amid lack of accountability for bias in maternity care, a California family seeks justice.
Citation Text:
Amid lack of accountability for bias in maternity care, a California family seeks justice. Kwon S. KFF Health News. August 8, 2023
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psnet.ahrq.gov/issue/care-clinician-after-adverse-event
March 03, 2021 - Review
Care of the clinician after an adverse event.
Citation Text:
Pratt SD, Jachna BR. Care of the clinician after an adverse event. Int J Obstet Anesth. 2014;24(1):54-63. doi:10.1016/j.ijoa.2014.10.001.
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psnet.ahrq.gov/issue/building-cultures-high-reliability-lessons-high-reliability-organization-paradigm
September 05, 2018 - Review
Building cultures of high reliability: lessons from the high reliability organization paradigm.
Citation Text:
Sutcliffe KM. Building cultures of high reliability: lessons from the high reliability organization paradigm. Anesthesiol Clin. 2023;41(4):707-717. doi:10.1016/j.anclin.2…
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psnet.ahrq.gov/issue/what-preventable-harm-healthcare-systematic-review-definitions
September 23, 2020 - Review
What is preventable harm in healthcare? A systematic review of definitions.
Citation Text:
Nabhan M, Elraiyah T, Brown DR, et al. What is preventable harm in healthcare? A systematic review of definitions. BMC Health Serv Res. 2012;12:128. doi:10.1186/1472-6963-12-128.
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psnet.ahrq.gov/issue/health-system-wont-learn-its-mistakes
October 26, 2022 - Commentary
A health system that won't learn from its mistakes.
Citation Text:
Keller C. A health system that won't learn from its mistakes. Health Aff (Millwood). 2022;41(9):1353-1356. doi:10.1377/hlthaff.2022.00581.
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psnet.ahrq.gov/node/43658/psn-pdf
December 19, 2014 - https://psnet.ahrq.gov/primer/handoffs-and-signouts
https://psnet.ahrq.gov/issue/interprofessional-approaches-patient-safety
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psnet.ahrq.gov/node/44702/psn-pdf
December 16, 2015 - that contribute to alarm
fatigue, this review outlines technical, organizational, and educational approaches