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psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - Situational Awareness and Patient Safety
April 1, 2016
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
The Case
A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - The "Customer" Is Always Right
February 1, 2007
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/customer-always-right
Case Objectives
Understand the importance of identifying a patient's agenda.
Appreciate the factors that contribute to unmet patient expectations.
…
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psnet.ahrq.gov/node/49642/psn-pdf
December 01, 2011 - Order Interrupted by Text: Multitasking Mishap
December 1, 2011
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
Case Objectives
State the prevalence of mobile devices among clinicians and their common health…
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psnet.ahrq.gov/node/41519/psn-pdf
September 01, 2016 - Failure to utilize functions of an electronic prescribing
system and the subsequent generation of 'technically
preventable' computerized alerts.
September 1, 2016
Baysari M, Reckmann MH, Li L, et al. Failure to utilize functions of an electronic prescribing system and the
subsequent generation of 'technically prev…
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psnet.ahrq.gov/node/45156/psn-pdf
June 22, 2017 - Workarounds to hospital electronic prescribing systems:
a qualitative study in English hospitals.
June 22, 2017
Cresswell K, Mozaffar H, Lee L, et al. Workarounds to hospital electronic prescribing systems: a qualitative
study in English hospitals. BMJ Qual Saf. 2017;26(7):542-551. doi:10.1136/bmjqs-2015-005149.
h…
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psnet.ahrq.gov/node/45344/psn-pdf
January 23, 2017 - Comparison of accuracy of physical examination findings
in initial progress notes between paper charts and a
newly implemented electronic health record.
January 23, 2017
Yadav S, Kazanji N, C. NK, et al. Comparison of accuracy of physical examination findings in initial
progress notes between paper charts and a ne…
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psnet.ahrq.gov/node/45905/psn-pdf
December 22, 2017 - Safe practice recommendations for the use of copy-
forward with nursing flow sheets in hospital settings.
December 22, 2017
Patterson ES, Sillars DM, Staggers N, et al. Safe Practice Recommendations for the Use of Copy-Forward
with Nursing Flow Sheets in Hospital Settings. Jt Comm J Qual Patient Saf. 2017;43(8):375…
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psnet.ahrq.gov/node/45323/psn-pdf
June 28, 2017 - Effects of health information technology on patient
outcomes: a systematic review.
June 28, 2017
Brenner SK, Kaushal R, Grinspan Z, et al. Effects of health information technology on patient outcomes: a
systematic review. J Am Med Inform Assoc. 2016;23(5):1016-36. doi:10.1093/jamia/ocv138.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/44766/psn-pdf
January 23, 2017 - Why do we still page each other? Examining the
frequency, types and senders of pages in academic
medical services.
January 23, 2017
Carlile N, Rhatigan JJ, Bates DW. Why do we still page each other? Examining the frequency, types and
senders of pages in academic medical services. BMJ Qual Saf. 2017;26(1):24-29. do…
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psnet.ahrq.gov/node/40171/psn-pdf
May 30, 2011 - Qualities and attributes of a safe practitioner:
identification of safety skills in healthcare.
May 30, 2011
Long S, Arora S, Moorthy K, et al. Qualities and attributes of a safe practitioner: identification of safety skills
in healthcare. BMJ Qual Saf. 2011;20(6):483-490. doi:10.1136/bmjqs.2010.043166.
https://ps…
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psnet.ahrq.gov/node/41941/psn-pdf
February 11, 2013 - A cross-sectional study on the relationship between
utilization of root cause analysis and patient safety at 139
Department of Veterans Affairs medical centers.
February 11, 2013
Percarpio KB, Watts V. A cross-sectional study on the relationship between utilization of root cause
analysis and patient safety at 139 …
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psnet.ahrq.gov/node/46956/psn-pdf
January 23, 2019 - Impact of a national QI programme on reducing electronic
health record notifications to clinicians.
January 23, 2019
Shah T, Patel-Teague S, Kroupa L, et al. Impact of a national QI programme on reducing electronic health
record notifications to clinicians. BMJ Qual Saf. 2018;28(1):10-14. doi:10.1136/bmjqs-2017-007…
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psnet.ahrq.gov/node/42007/psn-pdf
May 23, 2013 - Leaders' and followers' individual experiences during the
early phase of simulation-based team training: an
exploratory study.
May 23, 2013
Meurling L, Hedman L, Felländer-Tsai L, et al. Leaders' and followers' individual experiences during the
early phase of simulation-based team training: an exploratory study. B…
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psnet.ahrq.gov/web-mm/listen-family
April 15, 2015 - Listen to the Family
Citation Text:
Campbell D. Listen to the Family. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/comanagement-whos-charge
July 01, 2011 - Comanagement: Who's in Charge?
Citation Text:
Cheng HQ. Comanagement: Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/node/42946/psn-pdf
January 07, 2015 - Evaluation of medium-term consequences of
implementing commercial computerized physician order
entry and clinical decision support prescribing systems in
two 'early adopter' hospitals.
January 7, 2015
Cresswell K, Bates DW, Williams R, et al. Evaluation of medium-term consequences of implementing
commercial compu…
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psnet.ahrq.gov/node/45892/psn-pdf
October 31, 2017 - Relationship between state malpractice environment and
quality of health care in the United States.
October 31, 2017
Bilimoria KY, Chung JW, Minami CA, et al. Relationship Between State Malpractice Environment and
Quality of Health Care in the United States. Jt Comm J Qual Patient Saf. 2017;43(5):241-250.
doi:10.1…
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psnet.ahrq.gov/node/46481/psn-pdf
August 20, 2018 - An electronic trigger based on care escalation to identify
preventable adverse events in hospitalised patients.
August 20, 2018
Bhise V, Sittig DF, Vaghani V, et al. An electronic trigger based on care escalation to identify preventable
adverse events in hospitalised patients. BMJ Qual Saf. 2018;27(3):241-246. doi:…
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …