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psnet.ahrq.gov/issue/investigation-diagnostic-accuracy-and-confidence-associated-diagnostic-checklists-well-gender
February 21, 2024 - Study
An investigation of diagnostic accuracy and confidence associated with diagnostic checklists as well as gender biases in relation to mental disorders.
Citation Text:
Cwik JC, Papen F, Lemke J-E, et al. An Investigation of Diagnostic Accuracy and Confidence Associated with Diagnosti…
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psnet.ahrq.gov/issue/preventable-deaths-who-how-often-and-why
February 22, 2011 - Study
Classic
Preventable deaths: who, how often, and why?
Citation Text:
Dubois RW, Brook RH. Preventable deaths: who, how often, and why? Ann Intern Med. 1988;109(7):582-9.
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psnet.ahrq.gov/issue/impact-hindsight-bias-diagnosis-perioperative-events-anesthesia-providers-multicenter
December 16, 2020 - Study
The impact of hindsight bias on the diagnosis of perioperative events by anesthesia providers: a multicenter randomized crossover study.
Citation Text:
Millan PD, Kleiman AM, Friedman JF, et al. The impact of hindsight bias on the diagnosis of perioperative events by anesthesia pro…
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psnet.ahrq.gov/issue/commercialised-experience-operating-embodied-preferences-ambiguous-variations-and-explaining
August 24, 2022 - Study
The (commercialised) experience of operating: embodied preferences, ambiguous variations and explaining widespread patient harm.
Citation Text:
Ducey A, Donoso C, Ross S, et al. The (commercialised) experience of operating: embodied preferences, ambiguous variations and explaining …
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psnet.ahrq.gov/issue/more-holes-cheese-what-prevents-delivery-effective-high-quality-and-safe-healthcare-england
December 18, 2017 - Study
More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England?
Citation Text:
Hignett S, Lang A, Pickup L, et al. More holes than cheese. What prevents the delivery of effective, high quality and safe health care in England? Ergonomic…
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psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents
August 25, 2021 - Commentary
Classic
Human error and the problem of causality in analysis of accidents.
Citation Text:
Rasmussen J. Human error and the problem of causality in analysis of accidents. Philos Trans R Soc Lond B Biol Sci. 1990;327(1241):449-462.
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psnet.ahrq.gov/issue/promoting-patient-safety-using-early-warning-scoring-system
October 16, 2012 - Study
Promoting patient safety using an early warning scoring system.
Citation Text:
Higgins Y, Maries-Tillott C, Quinton S, et al. Promoting patient safety using an early warning scoring system. Nurs Stand. 2008;22(44):35-40.
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psnet.ahrq.gov/issue/cognitive-biases-regarding-utilization-emergency-severity-index-among-emergency-nurses
December 21, 2016 - Study
Cognitive biases regarding utilization of Emergency Severity Index among emergency nurses.
Citation Text:
Essa CD, Victor G, Khan SF, et al. Cognitive biases regarding utilization of emergency severity index among emergency nurses. Am J Emerg Med. 2023;73:63-68. doi:10.1016/j.ajem.…
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psnet.ahrq.gov/issue/learning-non-routine-events-and-teamwork-intensive-care-units-challenges-and-opportunities
September 11, 2019 - Commentary
Learning from non-routine events and teamwork in intensive care units: challenges and opportunities.
Citation Text:
Gong Y, Chen Y. Learning from non-routine events and teamwork in intensive care units: challenges and opportunities. Stud Health Technol Inform. 2024;310:324-328…
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psnet.ahrq.gov/issue/patient-safety-perception-within-hospitals-examination-job-type-handoffs-and-information
December 18, 2014 - Study
Patient safety perception within hospitals: an examination of job type, handoffs and information exchange, and hospital management support.
Citation Text:
Ming Y, Meehan R. Patient safety perception within hospitals: an examination of job type, handoffs and information exchange, an…
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psnet.ahrq.gov/issue/review-patient-safety-incidents-submitted-critical-care-units-england-wales-uk-national
July 16, 2008 - Study
Review of patient safety incidents submitted from critical care units in England & Wales to the UK National Patient Safety Agency.
Citation Text:
Thomas AN, Panchagnula U, Taylor RJ. Review of patient safety incidents submitted from Critical Care Units in England & Wales to the U…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-impmenu.pdf
June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time
Pressure Ulcer Healing
Menu of Implementation Strategies
The On-Time Menu of Process Improvement Strategies for using reports is a list of potential
ways facility teams may choose to integrate the pressure ulcer healing reports into clinical
practice. A menu of…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-impmenu.docx
June 02, 2025 - Agency for Healthcare Research and Quality Safety Program for Nursing Homes: On-Time Healing
AHRQ’s Safety Program for Nursing Homes: On-Time
Pressure Ulcer Healing
Menu of Implementation Strategies
The On-Time Menu of Process Improvement Strategies for using reports is a list of potential ways facility teams may choo…
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psnet.ahrq.gov/issue/test-result-communication-primary-care-clinical-and-office-staff-perspectives
November 20, 2015 - Study
Test result communication in primary care: clinical and office staff perspectives.
Citation Text:
Litchfield I, Bentham L, Lilford RJ, et al. Test result communication in primary care: clinical and office staff perspectives. Fam Pract. 2014;31(5):592-7. doi:10.1093/fampra/cmu041.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-test-result-communication5.html
July 01, 2024 - Electronic Test Result Communication in the Era of the 21st Century Cures Act
Discussion
Previous Page Next Page
Table of Contents
Electronic Test Result Communication in the Era of the 21st Century Cures Act
Introduction
Methods
Results
Discussion
Conclusions
References
Appendix A. Da…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/persell_cvd_disparities.pdf
June 02, 2025 - Reducing Disparities in the Primary Prevention of Cardiovascular Disease
Research Centers for Excellence
in Clinical Preventive Services
Working to get the right services, to the right people, at the right time
Reducing Disparities in the Primary
Prevention of Cardiovascular Disease…
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psnet.ahrq.gov/issue/debunking-myth-majority-medical-errors-are-attributed-communication
February 14, 2024 - Journal Article
Debunking the myth that the majority of medical errors are attributed to communication.
Citation Text:
Clapper TC, Ching K. Debunking the myth that the majority of medical errors are attributed to communication. Med Educ. 2020;54(1):74-81. doi:10.1111/medu.13821.
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www.ahrq.gov/hai/cauti-tools/archived-webinars/patient-family-engagement-ed-slides.html
December 01, 2017 - Patient and Family Engagement in the Emergency Department
Slide Presentation
Slide 1
Patient and Family Engagement in the ED
Sue Collier, RN, MSN, FABC
Clinical Content Development Lead
Health Research & Education Trust
American Hospital Association
Image: Photo of Sue Collier, RN.
Slide 2
Le…
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psnet.ahrq.gov/issue/relationship-staff-information-sharing-and-advice-networks-patient-safety-outcomes
June 22, 2011 - Study
Relationship of staff information sharing and advice networks to patient safety outcomes.
Citation Text:
Brewer BB, Carley KM, Benham-Hutchins MM, et al. Relationship of Staff Information Sharing and Advice Networks to Patient Safety Outcomes. J Nurs Adm. 2018;48(9):437-444. doi:10…
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psnet.ahrq.gov/issue/development-trigger-tool-identify-adverse-drug-events-elderly-patients-multimorbidity
December 02, 2020 - Study
Development of a trigger tool to identify adverse drug events in elderly patients with multimorbidity.
Citation Text:
Guzmán MDT, Banqueri MG, Otero MJ, et al. Development of a Trigger Tool to Identify Adverse Drug Events in Elderly Patients With Multimorbidity. J Patient Saf. 2021…