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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47376/psn-pdf
    November 02, 2018 - Assessing information sources to elucidate diagnostic process errors in radiologic imaging—a human factors framework. November 2, 2018 Cochon L, Lacson R, Wang A, et al. Assessing information sources to elucidate diagnostic process errors in radiologic imaging - a human factors framework. J Am Med Info Asso. 2018;…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851362/psn-pdf
    July 12, 2023 - Health system resilience, accreditation, high-quality care, and continuous quality improvement: what is the destination and how do we get there? July 12, 2023 Nicklin W, Greenfield D. Health system resilience, accreditation, high-quality care, and continuous quality improvement: what is the destination and how do …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839319/psn-pdf
    November 02, 2022 - Improving safety in the operating room: medication icon labels increase visibility and discrimination. November 2, 2022 Lusk C, Catchpole K, Neyens DM, et al. Improving safety in the operating room: medication icon labels increase visibility and discrimination. Appl Ergon. 2022;104:103831. doi:10.1016/j.apergo.2022…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34767/psn-pdf
    November 28, 2018 - Why Things Bite Back: Technology and the Revenge of Unintended Consequences. November 28, 2018 Tenner E. New York, NY: Knopf; 1996. ISBN: 0679425632. https://psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences Tenner’s discussions of medical and nonmedical examples provide an e…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38517/psn-pdf
    February 17, 2011 - Use of electronic health records in US hospitals. February 17, 2011 Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals. doi:10.1056/NEJMsa0900592. https://psnet.ahrq.gov/issue/use-electronic-health-records-us-hospitals Increasing the use of electronic health records (EHRs)…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48040/psn-pdf
    July 24, 2019 - Potentially inappropriate prescribing among older persons: a meta-analysis of observational studies. July 24, 2019 Liew TM, Lee CS, Shawn KLG, et al. Potentially Inappropriate Prescribing Among Older Persons: A Meta- Analysis of Observational Studies. Ann Fam Med. 2019;17(3):257-266. doi:10.1370/afm.2373. https://…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50933/psn-pdf
    February 26, 2020 - Medication-related harm in older adults following hospital discharge: development and validation of a prediction tool. February 26, 2020 Parekh N, Ali K, Davies JG, et al. Medication-related harm in older adults following hospital discharge: development and validation of a prediction tool. BMJ Qual Saf. 2020;29(2)…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45224/psn-pdf
    February 15, 2017 - Severe drug interactions and potentially inappropriate medication usage in elderly cancer patients. February 15, 2017 Alkan A, Ya?ar A, Karc? E, et al. Severe drug interactions and potentially inappropriate medication usage in elderly cancer patients. Support Care Cancer. 2017;25(1):229-236. https://psnet.ahrq.gov…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46103/psn-pdf
    September 23, 2017 - Polypharmacy in the elderly--when good drugs lead to bad outcomes: a teachable moment. September 23, 2017 Carroll C, Hassanin A. Polypharmacy in the Elderly-When Good Drugs Lead to Bad Outcomes: A Teachable Moment. JAMA Intern Med. 2017;177(6):871. doi:10.1001/jamainternmed.2017.0911. https://psnet.ahrq.gov/issue/…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50650/psn-pdf
    November 13, 2019 - Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study. November 13, 2019 Carson-Stevens A, Campbell S, Bell BG, et al. Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study. BMC Fam Pract. 2019;20(1):134. doi:10.1186/s12875…
  11. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit2-14.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 2.14. Major Factors that Facilitated Lean Success at Central Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Hea…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50802/psn-pdf
    January 15, 2020 - Use of error management theory to quantify and characterize residents' error recovery strategies. January 15, 2020 Pugh CM, Law KE, Cohen ER, et al. Use of error management theory to quantify and characterize residents’ error recovery strategies. Am J Surg. 2020;219(2):214-220. doi:10.1016/j.amjsurg.2019.11.013. h…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47807/psn-pdf
    March 13, 2019 - Unintended patient safety risks due to wireless smart infusion pump library update delays. March 13, 2019 Hsu K-Y, DeLaurentis P, Bitan Y, et al. Unintended Patient Safety Risks Due to Wireless Smart Infusion Pump Library Update Delays. J Patient Saf. 2019;15(1):e8-e14. doi:10.1097/PTS.0000000000000562. https://ps…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45389/psn-pdf
    September 27, 2016 - Prevalence of potentially inappropriate medication use in older adults living in nursing homes: a systematic review. September 27, 2016 Morin L, Laroche M-L, Texier G, et al. Prevalence of potentially inappropriate medication use in older adults living in nursing homes: a systematic review. J Am Med Dir Assoc. 2016…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35540/psn-pdf
    August 05, 2009 - Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. August 5, 2009 Solet DJ, Norvell M, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to- physician communication during patient handoffs. Acad Med. 2005;80(12):1094-9. …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47919/psn-pdf
    April 03, 2019 - How to Talk About Patient Safety. April 3, 2019 Hendricks R, O'Neil M, Volmert A. Boston, MA: Betsy Lehman Center for Patient Safety; March 2019. https://psnet.ahrq.gov/issue/how-talk-about-patient-safety This report suggests that the field of patient safety needs to be reframed for the public. The report recommen…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47618/psn-pdf
    January 30, 2019 - Making care better in the pediatric intensive care unit. January 30, 2019 Wolfe HA, Mack EH. Making care better in the pediatric intensive care unit. Transl Pediatr. 2018;7(4):267- 274. doi:10.21037/tp.2018.09.10. https://psnet.ahrq.gov/issue/making-care-better-pediatric-intensive-care-unit Pediatric critical care…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46455/psn-pdf
    April 24, 2018 - ISMP Medication Safety Self Assessment for High-Alert Medications. April 24, 2018 Horsham, PA: Institute for Safe Medication Practices; 2017. https://psnet.ahrq.gov/issue/ismp-medication-safety-self-assessment-high-alert-medications High-alert medications have the potential to cause substantial patient harm if adm…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47216/psn-pdf
    July 11, 2018 - Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed. July 11, 2018 Washington, DC: United States Government Accountability Office; May 2018. Publication GAO-18-380. https://psnet.ahrq.gov/issue/progress-made-towards-improving-opioid-safety-further-effort…
  20. digital.ahrq.gov/principal-investigator/alexander-gregory-l
    January 01, 2025 - Alexander, Gregory L. Emerging models of care using IT in long-term/post-acute care: A comparative analysis of human and AI-driven qualitative insights. Citation Alexander GL, Livingstone A, Han S, Chapman W, Comans T, Demiris G, Fisk M, Fossum M, Fung C, Kennedy R, O'Malley T…