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psnet.ahrq.gov/node/60851/psn-pdf
August 26, 2020 - Situativity: A Family of Social Cognitive Theories for
Clinical Reasoning and Error.
August 26, 2020
Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344.
https://psnet.ahrq.gov/issue/situativity-family-social-cognitive-theories-clinical-reasoning-and-error
Challenges to effective clinical reas…
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psnet.ahrq.gov/node/47632/psn-pdf
April 10, 2019 - Perception of the usability and implementation of a
metacognitive mnemonic to check cognitive errors in
clinical setting.
April 10, 2019
Chew KS, van Merrienboer JJG, Durning SJ. Perception of the usability and implementation of a
metacognitive mnemonic to check cognitive errors in clinical setting. BMC Med Educ. …
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psnet.ahrq.gov/node/837905/psn-pdf
August 24, 2022 - How cisgender clinicians can help prevent harm during
encounters with transgender patients.
August 24, 2022
doi:10.1001/amajethics.2022.753.
https://psnet.ahrq.gov/issue/how-cisgender-clinicians-can-help-prevent-harm-during-encounters-
transgender-patients
Implicit bias, discrimination, and stigmatization impact …
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psnet.ahrq.gov/node/45970/psn-pdf
March 22, 2017 - A learning health care system using computer-aided
diagnosis.
March 22, 2017
Cahan A, Cimino JJ. A Learning Health Care System Using Computer-Aided Diagnosis. J Med Internet
Res. 2017;19(3):e54. doi:10.2196/jmir.6663.
https://psnet.ahrq.gov/issue/learning-health-care-system-using-computer-aided-diagnosis
Although…
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psnet.ahrq.gov/node/764410/psn-pdf
March 02, 2022 - Five strategies for clinicians to advance diagnostic
excellence.
March 2, 2022
Singh H, Connor DM, Dhaliwal G. Five strategies for clinicians to advance diagnostic excellence. BMJ.
2022;376:e068044. doi:10.1136/bmj-2021-068044.
https://psnet.ahrq.gov/issue/five-strategies-clinicians-advance-diagnostic-excellence
…
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psnet.ahrq.gov/node/47597/psn-pdf
August 07, 2019 - Intentional rounding—an integrative literature review.
August 7, 2019
Ryan L, Jackson D, Woods C, et al. Intentional rounding - An integrative literature review. J Adv Nurs.
2019;75(6):1151-1161. doi:10.1111/jan.13897.
https://psnet.ahrq.gov/issue/intentional-rounding-integrative-literature-review
This review exam…
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psnet.ahrq.gov/node/839824/psn-pdf
November 09, 2022 - Improving diagnostic decision support through deliberate
reflection: a proposal.
November 9, 2022
Schmidt HG, Mamede S. Improving diagnostic decision support through deliberate reflection: a proposal.
Diagnosis (Berl). 2023;10(1):38-42. doi:10.1515/dx-2022-0062.
https://psnet.ahrq.gov/issue/improving-diagnostic-de…
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psnet.ahrq.gov/node/42911/psn-pdf
February 12, 2014 - Computerized physician order entry: promise, perils, and
experience.
February 12, 2014
Khanna R, Yen T. Computerized physician order entry: promise, perils, and experience. Neurohospitalist.
2014;4(1):26-33. doi:10.1177/1941874413495701.
https://psnet.ahrq.gov/issue/computerized-physician-order-entry-promise-peril…
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psnet.ahrq.gov/node/864864/psn-pdf
March 20, 2024 - Systemic failures in health care oversight.
March 20, 2024
Campbell JL. Ga L Rev. 2024;58(2):737-802.
https://psnet.ahrq.gov/issue/systemic-failures-health-care-oversight
Questions exist as to why practitioners with known performance issues continue to practice and affect
patient safety. This article suggests a sh…
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psnet.ahrq.gov/node/865345/psn-pdf
March 27, 2024 - The limits of clinician vigilance as an AI safety bulwark.
March 27, 2024
Adler-Milstein J, Redelmeier DA, Wachter RM. The limits of clinician vigilance as an AI safety bulwark.
JAMA. 2024;331(14):1173-1174. doi:10.1001/jama.2024.3620.
https://psnet.ahrq.gov/issue/limits-clinician-vigilance-ai-safety-bulwark
Human…
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psnet.ahrq.gov/node/74848/psn-pdf
February 16, 2022 - Patients for Patient Safety US.
February 16, 2022
404.510.8787; info@pfps.us
https://psnet.ahrq.gov/issue/patients-patient-safety-us
Patient safety improvement has made progress but more can be done. This organization supports
community efforts in the United States to engage policymakers in work toward aligning ef…
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psnet.ahrq.gov/node/43677/psn-pdf
November 19, 2014 - Reporting and Learning Systems for Medication Errors:
The Role of Pharmacovigilance Centres.
November 19, 2014
Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October
2014. ISBN: 9789241507943.
https://psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-err…
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psnet.ahrq.gov/node/46029/psn-pdf
October 11, 2017 - Closing the gap and raising the bar: assessing board
competency in quality and safety.
October 11, 2017
McGaffigan PA, Ullem BD, Gandhi TK. Closing the Gap and Raising the Bar: Assessing Board
Competency in Quality and Safety. Jt Comm J Qual Patient Saf. 2017;43(6):267-274.
doi:10.1016/j.jcjq.2017.03.003.
https:/…
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psnet.ahrq.gov/node/44863/psn-pdf
July 01, 2016 - Rating the raters: the inconsistent quality of health care
performance measurement.
July 1, 2016
Shahian DM, Normand S-LT, Friedberg MW, et al. Rating the Raters: The Inconsistent Quality of Health
Care Performance Measurement. Ann Surg. 2016;264(1):36-8. doi:10.1097/SLA.0000000000001631.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/42962/psn-pdf
September 07, 2016 - Drug Shortages: Public Health Threat Continues, Despite
Efforts to Help Ensure Product Availability.
September 7, 2016
Washington, DC: United States Government Accountability Office; February 10, 2014. Publication GAO-14-
194.
https://psnet.ahrq.gov/issue/drug-shortages-public-health-threat-continues-despite-effor…
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psnet.ahrq.gov/node/73639/psn-pdf
August 25, 2021 - The Safety of Maternity Services in England.
August 25, 2021
Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The
Stationery Office; July 6, 2021. Publication HC 19.
https://psnet.ahrq.gov/issue/safety-maternity-services-england
High-profile failures motivate examination …
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psnet.ahrq.gov/node/39197/psn-pdf
January 06, 2010 - root-cause-analysis
https://psnet.ahrq.gov/primer/never-events
https://psnet.ahrq.gov/issue/resident-duty-hours-enhancing-sleep-supervision-and-safety
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psnet.ahrq.gov/node/43027/psn-pdf
July 23, 2014 - improving-team-information-sharing-structured-call-out-anaesthetic-emergencies-randomized
https://psnet.ahrq.gov/issue/enhancing-patient-safety-during-hand-offs-standardized-communication-and-teamwork-using-sbar
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psnet.ahrq.gov/node/44513/psn-pdf
September 23, 2015 - recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care
teams, enhancing
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psnet.ahrq.gov/node/47516/psn-pdf
December 19, 2018 - Diverse stakeholders in Australia established an agenda for enhancing test result management,
which