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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;…
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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 …
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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…
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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…
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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)…
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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://…
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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)…
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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…
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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/…
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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…
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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…
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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…
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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…
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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…
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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.
…
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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…
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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…
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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…
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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…
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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…