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psnet.ahrq.gov/node/47167/psn-pdf
May 30, 2018 - AHRQ Health Information Technology Division's 2017
Annual Report.
May 30, 2018
Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0028-
EF.
https://psnet.ahrq.gov/issue/ahrq-health-information-technology-divisions-2017-annual-report
Health care has worked to enhance use…
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psnet.ahrq.gov/node/47726/psn-pdf
April 10, 2019 - Machine learning in medicine.
April 10, 2019
Rajkomar A, Dean J, Kohane IS. Machine Learning in Medicine. New Engl J Med. 2019;380(14):1347-
1358. doi:10.1056/NEJMra1814259.
https://psnet.ahrq.gov/issue/machine-learning-medicine
Machine learning in health care is in the early stage of application. This review expl…
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psnet.ahrq.gov/node/45298/psn-pdf
April 22, 2017 - The problem with root cause analysis.
April 22, 2017
Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417-
422. doi:10.1136/bmjqs-2016-005511.
https://psnet.ahrq.gov/issue/problem-root-cause-analysis
Root cause analysis (RCA) is a strategy to investigate incident…
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psnet.ahrq.gov/node/866967/psn-pdf
October 16, 2024 - Placing patient safety at the heart of value-based
healthcare.
October 16, 2024
La Regina M, Federici L, Bianco A, et al. Placing patient safety at the heart of value-based healthcare. Int J
Qual Health Care. 2024;36(3):mzae087. doi:10.1093/intqhc/mzae087.
https://psnet.ahrq.gov/issue/placing-patient-safety-heart-…
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psnet.ahrq.gov/node/60755/psn-pdf
August 05, 2020 - Patient safety from executive hospital management to
wards: a qualitative study identifying factors influencing
implementation.
August 5, 2020
Conner T, Unsworth J, Machin A. Patient safety from executive hospital management to wards: a
qualitative study identifying factors influencing implementation. J Nurs Manag…
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psnet.ahrq.gov/node/44725/psn-pdf
February 24, 2016 - Selected medication safety risks to manage in 2016 that
might otherwise fall off the radar screen—part 1 and part
2.
February 24, 2016
ISMP Medication Safety Alert! Acute care edition. January 28, 2016;21:1-4; February 11, 2016;21:1-5.
https://psnet.ahrq.gov/issue/selected-medication-safety-risks-manage-2016-might…
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psnet.ahrq.gov/node/847056/psn-pdf
April 05, 2023 - Early diagnosis of cancer: systems approach to support
clinicians in primary care.
April 5, 2023
Black GB, Lyratzopoulos G, Vincent CA, et al. Early diagnosis of cancer: systems approach to support
clinicians in primary care. BMJ. 2023;380:e071225. doi:10.1136/bmj-2022-071225.
https://psnet.ahrq.gov/issue/early-di…
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psnet.ahrq.gov/node/838256/psn-pdf
October 05, 2022 - Reinforcing the Value and Roles of Nurses in Diagnostic
Safety: Pragmatic Recommendations for Nurse Leaders
and Educators.
October 5, 2022
Tran AK, Calabrese M, Quatrara B, et al. Rockville, MD: Agency for Healthcare Research and Quality;
September 2022. AHRQ Publication No. 22-0026-4-EF.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/47737/psn-pdf
March 06, 2019 - Quality improvement and safety in pediatric emergency
medicine.
March 6, 2019
Ku BC, Chamberlain JM, Shaw KN. Quality Improvement and Safety in Pediatric Emergency Medicine.
Pediatr Clin North Am. 2018;65(6):1269-1281. doi:10.1016/j.pcl.2018.07.010.
https://psnet.ahrq.gov/issue/quality-improvement-and-safety-pedia…
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psnet.ahrq.gov/node/866824/psn-pdf
September 25, 2024 - 'Failing wisely' can promote a safer healthcare system.
September 25, 2024
Fleisher LA, Edmondson AC. 'Failing wisely' can promote a safer healthcare system. MedPage Today.
September 17, 2024;
https://psnet.ahrq.gov/issue/failing-wisely-can-promote-safer-healthcare-system
The ability to learn-by-doing in an enviro…
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psnet.ahrq.gov/node/47800/psn-pdf
June 26, 2019 - Error and Uncertainty in Diagnostic Radiology.
June 26, 2019
Bruno MA. New York, NY: Oxford University Press; 2019. ISBN: 9780190665395.
https://psnet.ahrq.gov/issue/error-and-uncertainty-diagnostic-radiology
Despite enhancements in medical imaging technology, diagnostic radiologists are still susceptible to
uncer…
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psnet.ahrq.gov/node/44795/psn-pdf
June 29, 2016 - Human factors in healthcare: welcome progress, but still
scratching the surface.
June 29, 2016
Waterson P, Catchpole K. Human factors in healthcare: welcome progress, but still scratching the surface.
BMJ Qual Saf. 2016;25(7):480-4. doi:10.1136/bmjqs-2015-005074.
https://psnet.ahrq.gov/issue/human-factors-healthca…
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psnet.ahrq.gov/node/46938/psn-pdf
April 25, 2018 - Diagnostic reasoning and cognitive biases of nurse
practitioners.
April 25, 2018
Lawson TN. Diagnostic Reasoning and Cognitive Biases of Nurse Practitioners. J Nurs Educ.
2018;57(4):203-208. doi:10.3928/01484834-20180322-03.
https://psnet.ahrq.gov/issue/diagnostic-reasoning-and-cognitive-biases-nurse-practitioners…
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psnet.ahrq.gov/node/45693/psn-pdf
February 22, 2017 - Meta-analyses of the effects of standardized handoff
protocols on patient, provider, and organizational
outcomes.
February 22, 2017
Keebler JR, Lazzara EH, Patzer BS, et al. Meta-Analyses of the Effects of Standardized Handoff Protocols
on Patient, Provider, and Organizational Outcomes. Hum Factors. 2016;58(8):118…
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psnet.ahrq.gov/node/45465/psn-pdf
September 07, 2016 - Improving patient safety culture in primary care: a
systematic review.
September 7, 2016
Verbakel NJ, Langelaan M, Verheij TJM, et al. Improving Patient Safety Culture in Primary Care: A
Systematic Review. J Patient Saf. 2016;12(3):152-8. doi:10.1097/PTS.0000000000000075.
https://psnet.ahrq.gov/issue/improving-pat…
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psnet.ahrq.gov/node/42915/psn-pdf
January 01, 2016 - Reducing Avoidable Readmissions Effectively campaign:
a statewide collaborative.
February 5, 2014
McCoy KA, Bear-Pfaffendorf K, Foreman JK, et al. Reducing Avoidable Hospital Readmissions Effectively:
A Statewide Campaign. Joint Comm J Qual Patient Saf. 2016;40(5):198-204, AP2. doi:10.1016/s1553-
7250(14)40026-6.
…
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psnet.ahrq.gov/node/866555/psn-pdf
August 21, 2024 - Using behavioral insights to strengthen strategies for
change. Practical applications for quality improvement in
healthcare.
August 21, 2024
Johansen RLR, Tulloch S. Using behavioral insights to strengthen strategies for change. Practical
applications for quality improvement in healthcare. J Patient Saf. 2024;20(5…
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psnet.ahrq.gov/node/45657/psn-pdf
March 08, 2017 - The causes of errors in clinical reasoning: cognitive
biases, knowledge deficits, and dual process thinking.
March 8, 2017
Norman GR, Monteiro SD, Sherbino J, et al. The Causes of Errors in Clinical Reasoning: Cognitive Biases,
Knowledge Deficits, and Dual Process Thinking. Acad Med. 2017;92(1):23-30.
doi:10.1097/…
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psnet.ahrq.gov/node/44853/psn-pdf
February 03, 2016 - Aviation and healthcare: a comparative review with
implications for patient safety.
February 3, 2016
Kapur N, Parand A, Soukup T, et al. Aviation and healthcare: a comparative review with implications for
patient safety. JRSM Open. 2016;7(1):2054270415616548. doi:10.1177/2054270415616548.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/46548/psn-pdf
April 16, 2018 - Nurses' communication of safety events to nursing home
residents and families.
April 16, 2018
Wagner LM, Driscoll L, Darlington JL, et al. Nurses' Communication of Safety Events to Nursing Home
Residents and Families. J Gerontol Nurs. 2018;44(2):25-32. doi:10.3928/00989134-20171002-01.
https://psnet.ahrq.gov/issue…