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psnet.ahrq.gov/node/38716/psn-pdf
February 17, 2011 - Ending extra payment for "never events"—stronger
incentives for patients' safety.
February 17, 2011
Milstein A. Ending extra payment for "never events"--stronger incentives for patients' safety. N Engl J Med.
2009;360(23):2388-90. doi:10.1056/NEJMp0809125.
https://psnet.ahrq.gov/issue/ending-extra-payment-never-ev…
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psnet.ahrq.gov/node/50416/psn-pdf
September 04, 2019 - Perceptual and interpretive error in diagnostic
radiology—causes and potential solutions.
September 4, 2019
Degnan AJ, Ghobadi EH, Hardy P, et al. Perceptual and Interpretive Error in Diagnostic Radiology-Causes
and Potential Solutions. Acad Radiol. 2019;26(6):833-845. doi:10.1016/j.acra.2018.11.006.
https://psnet…
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psnet.ahrq.gov/node/38332/psn-pdf
January 14, 2009 - Verifying patient identity and site of surgery: improving
compliance with protocol by audit and feedback.
January 14, 2009
Garnerin P, Arès M, Huchet A, et al. Verifying patient identity and site of surgery: improving compliance
with protocol by audit and feedback. Qual Saf Health Care. 2008;17(6):454-8.
doi:10.11…
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psnet.ahrq.gov/node/44952/psn-pdf
March 02, 2016 - Engaging pediatric resident physicians in quality
improvement through resident-led morbidity and mortality
conferences.
March 2, 2016
Destino LA, Kahana M, Patel SJ. Engaging Pediatric Resident Physicians in Quality Improvement Through
Resident-Led Morbidity and Mortality Conferences. Jt Comm J Qual Patient Saf. 2…
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psnet.ahrq.gov/node/36559/psn-pdf
July 14, 2010 - Description and evaluation of an interprofessional patient
safety course for health professions and related sciences
students.
July 14, 2010
Galt KA, Paschal KA, O'Brien RL, et al. Description and Evaluation of an Interprofessional Patient Safety
Course for Health Professions and Related Sciences Students. J Patie…
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psnet.ahrq.gov/node/45819/psn-pdf
March 15, 2017 - How doctors think: common diagnostic errors in clinical
judgment--lessons from an undiagnosed and rare disease
program.
March 15, 2017
Kliegman RM, Bordini BJ, Basel D, et al. How Doctors Think: Common Diagnostic Errors in Clinical
Judgment-Lessons from an Undiagnosed and Rare Disease Program. Pediatr Clin North A…
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psnet.ahrq.gov/node/60305/psn-pdf
May 06, 2020 - Medication safety: reducing anesthesia medication errors
and adverse drug events in dentistry part I and II.
May 6, 2020
Sarasin DS, Brady JW, Stevens RL. Anesth Prog. 2020;67(1):48-59.
https://psnet.ahrq.gov/issue/medication-safety-reducing-anesthesia-medication-errors-and-adverse-drug-
events-dentistry
Th…
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psnet.ahrq.gov/node/46626/psn-pdf
December 22, 2018 - What happened to my patient? An educational
intervention to facilitate postdischarge patient follow-up.
December 22, 2018
Narayana S, Rajkomar A, Harrison JD, et al. What Happened to My Patient? An Educational Intervention to
Facilitate Postdischarge Patient Follow-Up. J Grad Med Educ. 2017;9(5):627-633. doi:10.430…
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psnet.ahrq.gov/node/45166/psn-pdf
May 25, 2016 - Prevalence of inappropriate antibiotic prescriptions
among US ambulatory care visits, 2010–2011.
May 25, 2016
Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among
US Ambulatory Care Visits, 2010-2011. JAMA. 2016;315(17):1864-1873. doi:10.1001/jama.2016.4151.
htt…
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psnet.ahrq.gov/node/837810/psn-pdf
August 10, 2022 - Society for Maternal-Fetal Medicine Special Statement:
cognitive bias and medical error in obstetrics-challenges
and opportunities.
August 10, 2022
Atallah F, Hamm RF, Davidson CM, et al. Society for Maternal-Fetal Medicine Special Statement: Cognitive
bias and medical error in obstetrics-challenges and opportunit…
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psnet.ahrq.gov/node/48018/psn-pdf
July 31, 2019 - PEARLS for systems integration: a modified PEARLS
framework for debriefing systems-focused simulations.
July 31, 2019
Dubé MM, Reid J, Kaba A, et al. PEARLS for Systems Integration: A Modified PEARLS Framework for
Debriefing Systems-Focused Simulations. Simul Healthc. 2019;14(5):333-342.
doi:10.1097/SIH.0000000000…
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psnet.ahrq.gov/node/37193/psn-pdf
October 06, 2011 - Incomplete EHR adoption: late uptake of patient safety
and cost control functions.
October 6, 2011
Menachemi N, Ford E, Beitsch LM, et al. Incomplete EHR adoption: late uptake of patient safety and cost
control functions. Am J Med Qual. 2007;22(5):319-26.
https://psnet.ahrq.gov/issue/incomplete-ehr-adoption-late-u…
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psnet.ahrq.gov/node/838930/psn-pdf
October 26, 2022 - Artificial Intelligence in Health Care: Benefits and
Challenges of Machine Learning Technologies for Medical
Diagnostics.
October 26, 2022
Washington DC: United States Government Accountability Office and National Academy of
Medicine; September 2022. Report no. GAO-22-104629.
https://psnet.ahrq.gov/issue/ar…
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psnet.ahrq.gov/node/50424/psn-pdf
September 04, 2019 - From box ticking to the black box: the evolution of
operating room safety.
September 4, 2019
Goldenberg MG, Elterman D. From box ticking to the black box: the evolution of operating room safety.
World J Urol. 2019;38(6):1369-1372. doi:10.1007/s00345-019-02886-5.
https://psnet.ahrq.gov/issue/box-ticking-black-box-e…
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psnet.ahrq.gov/node/42655/psn-pdf
February 21, 2015 - Perceptions of medical errors in cancer care: an analysis
of how the news media describe sentinel events.
February 21, 2015
Li JW, Morway L, Velasquez A, et al. Perceptions of medical errors in cancer care: an analysis of how the
news media describe sentinel events. J Patient Saf. 2015;11(1):42-51.
doi:10.1097/PTS…
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psnet.ahrq.gov/node/44800/psn-pdf
November 23, 2016 - Patients' and families' perspectives of patient safety at the
end of life: a video-reflexive ethnography study.
November 23, 2016
Collier A, Sorensen R, Iedema R. Patients' and families' perspectives of patient safety at the end of life: a
video-reflexive ethnography study. Int J Qual Health Care. 2016;28(1):66-73.…
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psnet.ahrq.gov/node/44290/psn-pdf
April 10, 2023 - Retained surgical sponge (gossypiboma) and other
retained surgical items: prevention and management.
April 10, 2023
Copeland AW. UpToDate. April 10, 2023.
https://psnet.ahrq.gov/issue/retained-surgical-sponge-gossypiboma-and-other-retained-surgical-items-
prevention-and
Retained surgical items are rare and potent…
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psnet.ahrq.gov/node/47574/psn-pdf
November 21, 2018 - The architecture of safety: an emerging priority for
improving patient safety.
November 21, 2018
Joseph A, Henriksen K, Malone E. The Architecture Of Safety: An Emerging Priority For Improving Patient
Safety. Health Aff (Millwood). 2018;37(11):1884-1891. doi:10.1377/hlthaff.2018.0643.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/45341/psn-pdf
July 27, 2016 - How to avoid catastrophic events on the ward.
July 27, 2016
Bein B, Seewald S, Gräsner J-T. How to avoid catastrophic events on the ward. Best Pract Res Clin
Anaesthesiol. 2016;30(2):237-45. doi:10.1016/j.bpa.2016.04.003.
https://psnet.ahrq.gov/issue/how-avoid-catastrophic-events-ward
Hospitals require robust esca…
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psnet.ahrq.gov/node/839322/psn-pdf
November 02, 2022 - A perfect storm averted: flawed systems, a dropped ball,
and cognitive biases delay a critical diagnosis.
November 2, 2022
Roberts TJ, Sellars MC, Sands JM, et al. A perfect storm averted: flawed systems, a dropped ball, and
cognitive biases delay a critical diagnosis. JCO Oncol Pract. 2022;18(12):833-839.
doi:10.…