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psnet.ahrq.gov/node/37935/psn-pdf
February 17, 2011 - The (slowly) vanishing prescription pad.
February 17, 2011
Steinbrook R. The (slowly) vanishing prescription pad. N Engl J Med. 2008;359(2):115-7.
doi:10.1056/NEJMp0802864.
https://psnet.ahrq.gov/issue/slowly-vanishing-prescription-pad
This perspective discusses the proliferation of electronic vs. paper-based pres…
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psnet.ahrq.gov/node/37320/psn-pdf
November 07, 2007 - Ambulance crew in Chicago got lost trying to find
hospital.
November 7, 2007
News Services. Washington Post. October 25, 2007
https://psnet.ahrq.gov/issue/ambulance-crew-chicago-got-lost-trying-find-hospital
An emergency crew from a suburb failed to efficiently transport a marathon runner in cardiac arre…
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psnet.ahrq.gov/node/40276/psn-pdf
June 15, 2011 - The need for systems integration in health care.
June 15, 2011
Mathews SC, Pronovost P. The need for systems integration in health care. JAMA. 2011;305(9):934-5.
doi:10.1001/jama.2011.237.
https://psnet.ahrq.gov/issue/need-systems-integration-health-care
This commentary suggests a systems approach for implementing…
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psnet.ahrq.gov/taxonomy/term/3504
June 24, 2025 - Workaround
From the perspective of frontline personnel trying to accomplish their work, the design of equipment or the policies governing work tasks can seem counterproductive. When frontline personnel adopt consistent patterns of work or ways of bypassing safety features of medical equipment, these patterns and acti…
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psnet.ahrq.gov/node/60695/psn-pdf
July 15, 2020 - The coronavirus pandemic’s wider health-care crisis.
July 15, 2020
Khullar D. The coronavirus pandemic’s wider health-care crisis. New Yorker. 2020;Jun 29.
https://psnet.ahrq.gov/issue/coronavirus-pandemics-wider-health-care-crisis
The COVID-19 crisis has disrupted care delivery around the globe. This story discuss…
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psnet.ahrq.gov/node/73884/psn-pdf
September 29, 2021 - Dual surgeon operating to improve patient safety.
September 29, 2021
Ellis R, Hardie JA, Summerton DJ, et al. Dual surgeon operating to improve patient safety. Surg.
2021;59(7):752-756. doi:10.1016/j.bjoms.2021.02.014.
https://psnet.ahrq.gov/issue/dual-surgeon-operating-improve-patient-safety
Many non-urgent, non-…
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psnet.ahrq.gov/node/47795/psn-pdf
February 20, 2019 - Three laws for paperlessness.
February 20, 2019
Thimbleby H. Three laws for paperlessness. Digit Health. 2019;5:2055207619827722.
doi:10.1177/2055207619827722.
https://psnet.ahrq.gov/issue/three-laws-paperlessness
The digitization of health care data has had some positive effects on patient safety, but it has also…
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psnet.ahrq.gov/issue/randomized-trial-effectiveness-demand-versus-computer-triggered-drug-decision-support-primary
March 11, 2011 - Study
A randomized trial of the effectiveness of on-demand versus computer-triggered drug decision support in primary care.
Citation Text:
Tamblyn R, Huang A, Taylor L, et al. A randomized trial of the effectiveness of on-demand versus computer-triggered drug decision support in primar…
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psnet.ahrq.gov/issue/incidence-and-variables-associated-inconsistencies-opioid-prescribing-hospital-discharge-and
April 29, 2018 - Study
Incidence and variables associated with inconsistencies in opioid prescribing at hospital discharge and its associated adverse drug outcomes.
Citation Text:
Kurteva S, Habib B, Moraga T, et al. Incidence and variables associated with inconsistencies in opioid prescribing at hospita…
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psnet.ahrq.gov/issue/estimating-information-gap-between-emergency-department-records-community-medication-compared
March 11, 2011 - Study
Estimating the information gap between emergency department records of community medication compared to on-line access to the community-based pharmacy records.
Citation Text:
Tamblyn R, Poissant L, Huang A, et al. Estimating the information gap between emergency department records …
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psnet.ahrq.gov/node/36213/psn-pdf
September 30, 2010 - Patient self-medication--a change in hospital practice.
September 30, 2010
Grantham G, McMillan V, Dunn S, et al. Patient self-medication--a change in hospital practice. J Clin Nurs.
2006;15(8):962-70.
https://psnet.ahrq.gov/issue/patient-self-medication-change-hospital-practice
The investigators studied an inpati…
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psnet.ahrq.gov/node/865340/psn-pdf
March 27, 2024 - Risk management and patient safety in the artificial
intelligence era: a systematic review.
March 27, 2024
Ferrara M, Bertozzi G, Di Fazio N, et al. Risk management and patient safety in the artificial intelligence
era: a systematic review. Healthcare (Basel). 2024;12(5):549. doi:10.3390/healthcare12050549.
https:…
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psnet.ahrq.gov/node/40644/psn-pdf
October 04, 2020 - High-Performance Work Systems in Health Care
Management: Parts 1-5.
October 4, 2020
Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.
https://psnet.ahrq.gov/issue/high-performance-work-systems-health-care-management-part-1-and-part-2
In this continuing series, high-performance work pr…
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psnet.ahrq.gov/node/60566/psn-pdf
June 03, 2020 - Fear of Covid-19 leads other patients to decline critical
treatment.
June 3, 2020
Hafner K. Fear of Covid-19 leads other patients to decline critical treatment. New York Times. 2020;May
25.
https://psnet.ahrq.gov/issue/fear-covid-19-leads-other-patients-decline-critical-treatment
The uncertainties surrounding cor…
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psnet.ahrq.gov/node/50867/psn-pdf
February 05, 2020 - Cognitive testing of older clinicians prior to
recredentialing.
February 5, 2020
Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA.
2020;323(2):179-180. doi:10.1001/jama.2019.18665.
https://psnet.ahrq.gov/issue/cognitive-testing-older-clinicians-prior-recredentialing
In an…
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psnet.ahrq.gov/node/42257/psn-pdf
September 19, 2013 - The science of human factors: separating fact from
fiction.
September 19, 2013
Russ AL, Fairbanks RJ, Karsh B-T, et al. The science of human factors: separating fact from fiction. BMJ
Qual Saf. 2013;22(10):802-8. doi:10.1136/bmjqs-2012-001450.
https://psnet.ahrq.gov/issue/science-human-factors-separating-fact-fict…
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psnet.ahrq.gov/node/37821/psn-pdf
June 11, 2008 - Full work analysis of resident work hours.
June 11, 2008
Dassinger MS, Eubanks JW, Langham MR. Full work analysis of resident work hours. J Surg Res.
2008;147(2):178-81. doi:10.1016/j.jss.2008.03.010.
https://psnet.ahrq.gov/issue/full-work-analysis-resident-work-hours
A time-motion study of surgical residents foun…
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psnet.ahrq.gov/node/33882/psn-pdf
June 01, 2019 - Building a Safety Program Using Principles of Resilience
Engineering
June 1, 2019
Hegde S, Fairbanks RJ, Bisantz A. Building a Safety Program Using Principles of Resilience Engineering.
PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
Persp…
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psnet.ahrq.gov/node/38677/psn-pdf
August 18, 2010 - Impact of a computerized physician order-entry system.
August 18, 2010
Stone WM, Smith BE, Shaft JD, et al. Impact of a computerized physician order-entry system. J Am Coll
Surg. 2009;208(5):960-7; discussion 967-9. doi:10.1016/j.jamcollsurg.2009.01.042.
https://psnet.ahrq.gov/issue/impact-computerized-physician-or…
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psnet.ahrq.gov/node/41912/psn-pdf
December 12, 2012 - Speaking up and sharing information improves trainee
neonatal resuscitations.
December 12, 2012
Katakam LI, Trickey AW, Thomas EJ. Speaking up and sharing information improves trainee neonatal
resuscitations. J Patient Saf. 2012;8(4):202-9. doi:10.1097/PTS.0b013e3182699b4f.
https://psnet.ahrq.gov/issue/speaking-an…