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psnet.ahrq.gov/issue/risk-mistaken-dnr-orders
October 19, 2022 - Study
Risk of mistaken DNR orders.
Citation Text:
Rohrer JE, Esler WV, Saeed Q, et al. Risk of mistaken DNR orders. Supportive Care in Cancer. 2006;14(8). doi:10.1007/s00520-006-0023-z.
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psnet.ahrq.gov/issue/audit-handover-ent-unit
October 28, 2020 - Study
Audit of handover in an ENT unit.
Citation Text:
Ellul D, Robson AK. Audit of handover in an ENT unit. J Laryngol Otol. 2011;125(9):924-7. doi:10.1017/S0022215111000880.
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psnet.ahrq.gov/issue/systems-science-primer-high-reliability
March 23, 2022 - Review
Systems science: a primer on high reliability.
Citation Text:
Roberson DW, Kirsh ER. Systems science: a primer on high reliability. Otolaryngol Clin North Am. 2019;52(1):1-9. doi:10.1016/j.otc.2018.08.001.
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psnet.ahrq.gov/issue/managing-unexpected-sustained-performance-complex-world-3rd-edition
November 04, 2015 - Book/Report
Classic
Managing the Unexpected: Sustained Performance in a Complex World, Third Edition.
Citation Text:
Managing the Unexpected: Sustained Performance in a Complex World, Third Edition. Weick KE, Sutcliffe KM. San Francisco, CA: Jossey-Bass; 2015. I…
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psnet.ahrq.gov/issue/safe-operation-social-construct
August 07, 2019 - Commentary
Safe operation as a social construct.
Citation Text:
Rochlin GI. Safe operation as a social construct. Ergonomics. 2002;42(11):1549-1560. doi:10.1080/001401399184884.
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psnet.ahrq.gov/issue/optimizing-medication-safety-home
August 24, 2015 - Study
Optimizing medication safety in the home.
Citation Text:
LeBlanc RG, Choi J. Optimizing medication safety in the home. Home Healthc Now. 2015;33(6):313-319. doi:10.1097/NHH.0000000000000246.
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psnet.ahrq.gov/issue/peer-support-clinicians-programmatic-approach
July 25, 2018 - Commentary
Peer support for clinicians: a programmatic approach.
Citation Text:
Shapiro J, Galowitz P. Peer Support for Clinicians: A Programmatic Approach. Acad Med. 2016;91(9):1200-4. doi:10.1097/ACM.0000000000001297.
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psnet.ahrq.gov/issue/swift-new-tool-identifying-prospective-hazards
February 03, 2021 - Commentary
Beyond FMEA: the structured what-if technique (SWIFT).
Citation Text:
Card AJ, Ward JR, Clarkson PJ. Beyond FMEA: The structured what-if technique (SWIFT). J Healthc Risk Manag. 2012;31(4):23-29. doi:10.1002/jhrm.20101.
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psnet.ahrq.gov/issue/understanding-why-quality-initiatives-succeed-or-fail-sociotechnical-systems-perspective
March 10, 2021 - Commentary
Understanding why quality initiatives succeed or fail: a sociotechnical systems perspective.
Citation Text:
Wiegmann DA. Understanding Why Quality Initiatives Succeed or Fail: A Sociotechnical Systems Perspective. Ann Surg. 2016;263(1):9-11. doi:10.1097/SLA.0000000000001333.
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psnet.ahrq.gov/issue/how-safe-your-care-measurement-and-monitoring-safety-through-eyes-patients-and-their-care
August 16, 2016 - Book/Report
How Safe is Your Care? Measurement and Monitoring of Safety Through the Eyes of Patients and Their Care Partners.
Citation Text:
How Safe is Your Care? Measurement and Monitoring of Safety Through the Eyes of Patients and Their Care Partners. Jefs L, Kuluski K, MacLaurin A, e…
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psnet.ahrq.gov/issue/artificial-intelligence-health-care-benefits-and-challenges-technologies-augment-patient-care
January 08, 2014 - Book/Report
Artificial Intelligence in Health Care: Benefits and Challenges of Technologies to Augment Patient Care.
Citation Text:
Artificial Intelligence in Health Care: Benefits and Challenges of Technologies to Augment Patient Care. Washington DC; United States Government Accountabil…
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psnet.ahrq.gov/issue/becoming-high-reliability-organization-through-shared-learning-safety-events
February 12, 2020 - Newspaper/Magazine Article
Becoming a high-reliability organization through shared learning of safety events
Citation Text:
Becoming a high-reliability organization through shared learning of safety events Klenklen J. Patient Saf Qual HCare. December 19, 2019.
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psnet.ahrq.gov/issue/human-factors-healthcare
May 01, 2013 - Special or Theme Issue
Human Factors In Healthcare.
Citation Text:
Human Factors In Healthcare. Keebler JR, Salas E, Rosen MA, et al. eds. Hum Factors. 2022;64(1):5-258.
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psnet.ahrq.gov/issue/hidden-danger-obvious-opportunity-error-and-risk-management-cancer
June 07, 2018 - Commentary
Hidden danger, obvious opportunity: error and risk in the management of cancer.
Citation Text:
Munro AJ. Hidden danger, obvious opportunity: error and risk in the management of cancer. Br J Radiol. 2007;80(960):955-66.
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psnet.ahrq.gov/issue/acog-committee-opinion-590-preparing-clinical-emergencies-obstetrics-and-gynecology
May 22, 2019 - Commentary
ACOG Committee Opinion #590: preparing for clinical emergencies in obstetrics and gynecology.
Citation Text:
Improvement AC of O and GC on PS and Q. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014;123(3):722-5. d…
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psnet.ahrq.gov/issue/acog-committee-opinion-546-tracking-and-reminder-systems
May 22, 2019 - Commentary
ACOG Committee Opinion #546: tracking and reminder systems.
Citation Text:
Improvement AC of O and GC on PS and Q. Committee Opinion No.546: Tracking and reminder systems. Obstet Gynecol. 2012;120(6):1535-7. doi:10.1097/01.AOG.0000423820.92906.d0.
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psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review
June 19, 2019 - Review
Organizational learning in hospitals: a realist review.
Citation Text:
Lyman B, Jacobs JD, Hammond EL, et al. Organizational learning in hospitals: A realist review. J Adv Nurs. 2019;75(11):2352-2377. doi:10.1111/jan.14091.
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psnet.ahrq.gov/issue/strategies-improve-patient-safety-final-report-congress-required-patient-safety-and-quality
June 21, 2016 - Book/Report
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.
Citation Text:
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.…
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psnet.ahrq.gov/issue/twelve-tips-engaging-learners-checking-health-care-decisions
February 27, 2014 - Commentary
Twelve tips on engaging learners in checking health care decisions.
Citation Text:
Sibbald M, de Bruin A, van Merrienboer JJG. Twelve tips on engaging learners in checking health care decisions. Med Teach. 2014;36(2):111-5. doi:10.3109/0142159X.2013.847910.
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psnet.ahrq.gov/issue/pridx-framework-engage-payers-reducing-diagnostic-errors-healthcare
January 22, 2025 - Commentary
The PRIDx framework to engage payers in reducing diagnostic errors in healthcare.
Citation Text:
Ali KJ, Goeschel CA, DeLia DM, et al. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare. Diagnosis (Berl). 2024;11(1):17-24. doi:10.1515/dx-2023-0042…