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psnet.ahrq.gov/node/50696/psn-pdf
November 27, 2019 - ’s own root cause analysis found that there was no process in place for
collaborative, adjudicated decision-making
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psnet.ahrq.gov/node/33737/psn-pdf
September 01, 2012 - To better inform decision making on health workforce policy, a priority of the Center is to develop and
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psnet.ahrq.gov/node/34772/psn-pdf
November 18, 2015 - Sensemaking in Organizations.
November 18, 2015
Weick KE. Thousand Oaks, CA: Sage Publications; 1995. ISBN: 9780803971776.
https://psnet.ahrq.gov/issue/sensemaking-organizations
Weick's work has influenced many important thinkers in patient safety, most notably Don Berwick, as seen
in his story Escape Fire, which …
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psnet.ahrq.gov/node/33745/psn-pdf
February 01, 2013 - that passive engagement activities, such as finding a doctor or nurse and
participating in medical decision … making, may have a more potent impact on reducing adverse events than
the more active behaviors, such
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psnet.ahrq.gov/primers-0
March 15, 2025 - Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Latest Primers
Clinical Decision Support Systems
March…
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psnet.ahrq.gov/issue/identification-and-characterization-adverse-drug-events-primary-care
July 16, 2015 - Study
Identification and characterization of adverse drug events in primary care.
Citation Text:
Trinkley KE, Weed HG, Beatty SJ, et al. Identification and Characterization of Adverse Drug Events in Primary Care. Am J Med Qual. 2017;32(5):518-525. doi:10.1177/1062860616665695.
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psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
September 01, 2007 - The hard part is having the ideas that illustrate the real world of decision-making and morbidity, having
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psnet.ahrq.gov/node/33847/psn-pdf
August 01, 2017 - What I'd like to see is a bundled approach where we have valid, reliable measures in
decision-making
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psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
March 10, 2021 - as partners and essential members of the healthcare team with perspectives critical to the clinical decision-making … Board (hospital governance)
TCPI PFE Measures:
Support for Patient and Family Voices
Shared … Decision-Making
Patient Activation
Active e-Tool
Health Literacy Survey
Medication Management
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psnet.ahrq.gov/node/49658/psn-pdf
July 01, 2012 - Misleading Complaint
July 1, 2012
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/misleading-complaint
The Case
A 54-year-old homeless man with a history of alcoholism presented to the emergency department (ED) with
complaints of knee problems. The triage nurse docu…
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psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - be greater focus thinking about what can be done to test the environment and how that can enhance
decision … making about the built environment. … at in water transmission to kill
bacteria and viruses, I think are going to start coming into the decision-making
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psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - Investigators found that patients who reported more engagement in decision-making maintained more trust … The authors suggest that shared decision-making may mitigate some of the loss of trust associated with
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - Shared decision making with the patient is imperative. 13 Assessment of patient ability is also important … hospital-supplied blood glucose meter are typically necessary for documentation in the EHR and for insulin dosage decision-making
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psnet.ahrq.gov/node/850349/psn-pdf
June 14, 2023 - Cognitive biases in internal medicine: a scoping review.
June 14, 2023
Loncharich MF, Robbins RC, Durning SJ, et al. Cognitive biases in internal medicine: a scoping review.
Diagnosis (Berl). 2023;10(3):205-214. doi:10.1515/dx-2022-0120.
https://psnet.ahrq.gov/issue/cognitive-biases-internal-medicine-scoping-review…
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psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
February 26, 2025 - In Conversation With…Christine A. Sinsky, MD
February 1, 2016
Citation Text:
In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - Standardization Given the limits of standardization with regard to complex systems with constant trade-offs in decision-making
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - cognitive
errors ignores the reality that heuristics are a powerful and useful component of clinical decision-making … of this
technique comes from framing the conversation so that critical information intended to spur decision … -
making is brought “front and center.”
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psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
April 01, 2005 - Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet)
Robert M. Wachter, MD | April 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wachter R. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Ne…
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psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
April 01, 2005 - In Conversation with…Christopher P. Landrigan, MD
April 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/issue/information-distortion-physicians-diagnostic-judgments
April 07, 2021 - Study
Information distortion in physicians' diagnostic judgments.
Citation Text:
Kostopoulou O, Russo E, Keenan G, et al. Information distortion in physicians' diagnostic judgments. Med Decis Making. 2012;32(6):831-9. doi:10.1177/0272989X12447241.
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