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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/839834/psn-pdf
November 09, 2022 - Medicare fines for high hospital readmissions drop, but
nearly 2,300 facilities are still penalized.
November 9, 2022
Rau J. Kaiser Health News. November 1, 2022.
https://psnet.ahrq.gov/issue/medicare-fines-high-hospital-readmissions-drop-nearly-2300-facilities-are-still-
penalized
The COVID-19 pandemic nec…
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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/44677/psn-pdf
June 07, 2016 - Computerised prescribing for safer medication ordering:
still a work in progress.
June 7, 2016
Schiff G, Hickman T-TT, Volk LA, et al. Computerised prescribing for safer medication ordering: still a work
in progress. BMJ Qual Saf. 2016;25(5):315-9. doi:10.1136/bmjqs-2015-004677.
https://psnet.ahrq.gov/issue/comput…
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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.…
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psnet.ahrq.gov/node/46175/psn-pdf
September 24, 2017 - Applying lessons from social psychology to transform the
culture of error disclosure.
September 24, 2017
Han J, LaMarra D, Vapiwala N. Applying lessons from social psychology to transform the culture of error
disclosure. Med Educ. 2017;51(10):996-1001. doi:10.1111/medu.13345.
https://psnet.ahrq.gov/issue/applying-…
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psnet.ahrq.gov/node/46426/psn-pdf
September 28, 2017 - Toward more proactive approaches to safety in the
electronic health record era.
September 28, 2017
Sittig DF, Singh H. Toward More Proactive Approaches to Safety in the Electronic Health Record Era. Jt
Comm J Qual Patient Saf. 2017;43(10):540-547. doi:10.1016/j.jcjq.2017.06.005.
https://psnet.ahrq.gov/issue/toward…
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psnet.ahrq.gov/node/46315/psn-pdf
December 16, 2017 - Recognition and prevention of nosocomial malnutrition: a
review and a call to action!
December 16, 2017
Kirkland LL, Shaughnessy E. Recognition and Prevention of Nosocomial Malnutrition: A Review and A Call
to Action!. Am J Med. 2017;130(12):1345-1350. doi:10.1016/j.amjmed.2017.07.034.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/46011/psn-pdf
January 17, 2018 - Health and Social Care Ergonomics: Patient Safety in
Practice.
January 17, 2018
Hignett S, Albolino S, Catchpole K, eds. Ergonomics. 2018;61:1-161.
https://psnet.ahrq.gov/issue/health-and-social-care-ergonomics-patient-safety-practice
Human factors engineering strategies offer a range of solutions to improve proce…
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psnet.ahrq.gov/node/45669/psn-pdf
January 23, 2017 - Overdiagnosis of coronary artery disease detected by
coronary computed tomography angiography: a
teachable moment.
January 23, 2017
Schmidt T, Maag R, Foy AJ. Overdiagnosis of Coronary Artery Disease Detected by Coronary Computed
Tomography Angiography: A Teachable Moment. JAMA Intern Med. 2016;176(12):1747-1748.
…
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psnet.ahrq.gov/node/44210/psn-pdf
September 09, 2015 - The future of graduate medical education: a systems-
based approach to ensure patient safety.
September 9, 2015
Bagian JP. The Future of Graduate Medical Education: A Systems-Based Approach to Ensure Patient
Safety. Acad Med. 2015;90(9):1199-202. doi:10.1097/ACM.0000000000000824.
https://psnet.ahrq.gov/issue/futur…
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psnet.ahrq.gov/node/851665/psn-pdf
July 26, 2023 - Adverse Events Toolkit: Medical Record Review
Methodology.
July 26, 2023
Maxwell A. Washington, DC: US Department of Health and Human Services, Office of the Inspector
General; July 2023. Report no. OEI-06-21-00030.
https://psnet.ahrq.gov/issue/adverse-events-toolkit-medical-record-review-methodology
Medical…
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psnet.ahrq.gov/node/849122/psn-pdf
May 17, 2023 - Structural racism in behavioral health presentation and
management.
May 17, 2023
Rainer T, Lim JK, He Y, et al. Structural racism in behavioral health presentation and management. Hosp
Pediatr. 2023;13(5):461-470. doi:10.1542/hpeds.2023-007133.
https://psnet.ahrq.gov/issue/structural-racism-behavioral-health-prese…
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psnet.ahrq.gov/node/838193/psn-pdf
September 28, 2022 - Economics of Medication Safety. Improving Medication
Safety Through Collective, Real-time Learning.
September 28, 2022
de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and
Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.
…