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psnet.ahrq.gov/issue/health-information-technology-leadership-panel-final-report
March 30, 2022 - Government Resource
Health Information Technology Leadership Panel: Final Report.
Citation Text:
Health Information Technology Leadership Panel: Final Report. Lewin Group: Falls Church, VA; March 2005.
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psnet.ahrq.gov/issue/learning-incidents-health-care-critique-safety-ii-perspective
August 19, 2020 - Commentary
Learning from incidents in health care: critique from a Safety-II perspective.
Citation Text:
Learning from incidents in health care: critique from a Safety-II perspective. Sujan MA, Huang H, Braithwaite J. Safety Sci. 2017;99:115-121.
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psnet.ahrq.gov/issue/medication-error-care-hivaids-patients-electronic-surveillance-confirmation-and-adverse
September 28, 2022 - Study
Medication error in the care of HIV/AIDS patients: electronic surveillance, confirmation, and adverse events.
Citation Text:
DeLorenze GN, Follansbee SF, Nguyen DP, et al. Medication error in the care of HIV/AIDS patients: electronic surveillance, confirmation, and adverse events…
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psnet.ahrq.gov/issue/moving-beyond-implicit-bias-antiracist-academic-medicine-initiatives
May 18, 2022 - Commentary
Moving beyond implicit bias in antiracist academic medicine initiatives.
Citation Text:
Calhoun A, Genao I, Martin A, et al. Moving beyond implicit bias in antiracist academic medicine initiatives. Acad Med. 2022;97(6):790-792. doi:10.1097/acm.0000000000004562.
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psnet.ahrq.gov/issue/huddles-and-debriefings-improving-communication-labor-and-delivery
February 13, 2013 - Review
Huddles and debriefings: improving communication on labor and delivery.
Citation Text:
McQuaid-Hanson E, Pian-Smith MCM. Huddles and Debriefings: Improving Communication on Labor and Delivery. Anesthesiol Clin. 2017;35(1):59-67. doi:10.1016/j.anclin.2016.09.006.
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psnet.ahrq.gov/issue/when-less-more-role-overdiagnosis-and-overtreatment-patient-safety
July 22, 2020 - Commentary
When less is more: the role of overdiagnosis and overtreatment in patient safety.
Citation Text:
Kamzan AD, Ng E. When less is more: the role of overdiagnosis and overtreatment in patient safety. Adv Pediatr. 2021;68:21-35. doi:10.1016/j.yapd.2021.05.013.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-sbs.pdf
June 02, 2025 - NICU Family Information Packet, Appendix B, Short Bowel Syndrome
Short Bowel Syndrome
Pathophysiology
■ Functional disorder caused by alterations of normal intestinal anatomy and physiology.
■ Shortened bowel combined with malabsorption; dependent on parenteral nutrition >3 months.
■ May result from: necrotizin…
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psnet.ahrq.gov/issue/only-1-5-people-opioid-addiction-get-medications-treat-it-study-finds
October 21, 2020 - Newspaper/Magazine Article
Only 1 in 5 people with opioid addiction get the medications to treat it, study finds.
Citation Text:
Only 1 in 5 people with opioid addiction get the medications to treat it, study finds. Mann B. Health Shots. National Public Radio. August 7, 2023.
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psnet.ahrq.gov/issue/pediatric-vaccination-errors-application-5-rights-framework-national-error-reporting-database
September 21, 2008 - Study
Pediatric vaccination errors: application of the "5 rights" framework to a national error reporting database.
Citation Text:
Bundy DG, Shore AD, Morlock L, et al. Pediatric vaccination errors: application of the "5 rights" framework to a national error reporting database. Vaccine.…
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psnet.ahrq.gov/issue/request-information-creating-national-healthcare-system-action-alliance-advance-patient
June 22, 2022 - Press Release/Announcement
Request for Information: Creating a National Healthcare System Action Alliance to Advance Patient Safety.
Citation Text:
Request for Information: Creating a National Healthcare System Action Alliance to Advance Patient Safety. Agency for Healthcare Research and…
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psnet.ahrq.gov/issue/evaluation-12-strategies-obtaining-second-opinions-improve-interpretation-breast
November 03, 2015 - Study
Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study.
Citation Text:
Elmore JG, Tosteson AN, Pepe MS, et al. Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histo…
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www.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-compendium-self-assessment-instructions.pdf
December 01, 2023 - How to Complete the Practice Self-Assessment Tool for Opioid Use in Older Adults
www.ahrq.gov
How to Complete the Practice Self-Assessment Tool for Opioid Use in Older Adults
The Practice Self-Assessment Tool for Opioid Use in Older Adults (Self-Assessment tool) is for
primary care practices that want to improve…
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psnet.ahrq.gov/issue/fda-advises-health-care-professionals-and-patients-about-insulin-pen-packaging-and-dispensing
June 22, 2011 - Press Release/Announcement
FDA advises health care professionals and patients about insulin pen packaging and dispensing.
Citation Text:
FDA advises health care professionals and patients about insulin pen packaging and dispensing. MedWatch Safety Alert. Silver Spring, MD: US Food and Dr…
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psnet.ahrq.gov/issue/excessive-work-hours-physicians-training-el-salvador-putting-patients-risk
August 04, 2021 - Commentary
Excessive work hours of physicians in training in El Salvador: putting patients at risk.
Citation Text:
Taylor KRF. Excessive work hours of physicians in training in El Salvador: putting patients at risk. PLoS Med. 2007;4(7):e205.
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psnet.ahrq.gov/issue/education-and-reporting-diagnostic-errors-among-physicians-internal-medicine-training
July 17, 2019 - Study
Education and reporting of diagnostic errors among physicians in internal medicine training programs.
Citation Text:
Wijesekera TP, Sanders L, Windish DM. Education and Reporting of Diagnostic Errors Among Physicians in Internal Medicine Training Programs. JAMA Intern Med. 2018;178…
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psnet.ahrq.gov/issue/critical-deficiencies-washington-dc-va-medical-center
December 16, 2020 - Government Resource
Critical Deficiencies at the Washington DC VA Medical Center.
Citation Text:
Critical Deficiencies at the Washington DC VA Medical Center. Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. Report No. 17-02644-130.
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psnet.ahrq.gov/issue/medication-error-identification-rates-pharmacy-medical-and-nursing-students
June 02, 2021 - Study
Medication error identification rates by pharmacy, medical, and nursing students.
Citation Text:
Warholak TL, Queiruga C, Roush R, et al. Medication error identification rates by pharmacy, medical, and nursing students. Am J Pharm Educ. 2011;75(2):24.
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psnet.ahrq.gov/issue/incidence-accidental-awareness-during-general-anaesthesia-obstetrics-multicentre-prospective
December 10, 2024 - Study
Emerging Classic
Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study.
Citation Text:
Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective coho…
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psnet.ahrq.gov/issue/whats-changed-1-year-after-radonda-vaughts-conviction
October 13, 2021 - Newspaper/Magazine Article
What's changed 1 year after RaDonda Vaught's conviction?
Citation Text:
What's changed 1 year after RaDonda Vaught's conviction? Bean M, Carbajal E. Becker's Hospital Review. March 29, 2023.
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psnet.ahrq.gov/issue/cardiovascular-medication-errors-children
September 21, 2008 - Study
Cardiovascular medication errors in children.
Citation Text:
Alexander DC, Bundy DG, Shore AD, et al. Cardiovascular medication errors in children. Pediatrics. 2009;124(1):324-32. doi:10.1542/peds.2008-2073.
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