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psnet.ahrq.gov/issue/breast-cancer-missed-screening-hindsight-or-mistakes
November 15, 2023 - January 29, 2020
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/discrepancies-between-clinical-and-autopsy-diagnosis-and-value-post-mortem-histology-meta
September 22, 2021 - March 23, 2012
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
June 01, 2010 - handoffs as well as guidelines for procedures and checklists should be developed, implemented, and evaluated … However, such tools as computerized physician order entry have not been evaluated to clarify the benefits
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psnet.ahrq.gov/node/73971/psn-pdf
October 13, 2021 - Safety culture as a patient safety practice for alarm
fatigue.
October 13, 2021
Winters BD, Slota JM, Bilimoria KY. Safety culture as a patient safety practice for alarm fatigue. JAMA.
2021;326(12):1207-1208. doi:10.1001/jama.2021.8316.
https://psnet.ahrq.gov/issue/safety-culture-patient-safety-practice-alarm-fati…
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psnet.ahrq.gov/node/45367/psn-pdf
September 28, 2016 - How PSOs Help Health Care Organizations Improve
Patient Safety Culture.
September 28, 2016
Rockville, MD: Agency for Healthcare Research and Quality; April 2016. AHRQ Pub. No. 16-0026-EF.
https://psnet.ahrq.gov/issue/how-psos-help-health-care-organizations-improve-patient-safety-culture
Patient safety organization…
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psnet.ahrq.gov/node/47954/psn-pdf
August 07, 2019 - Special Issue on Resilience Engineering and High
Reliability Organizations.
August 7, 2019
Wears RL, Roberts KH, eds. Safety Sci. 2019;117;458-533.
https://psnet.ahrq.gov/issue/special-issue-resilience-engineering-and-high-reliability-organizations
Resilience is an organizational characteristic that enables indivi…
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psnet.ahrq.gov/node/45503/psn-pdf
October 29, 2017 - All CLEAR? Preparing for IT downtime.
October 29, 2017
Kashiwagi DT, Sexton MD, Graves ES, et al. All CLEAR? Preparing for IT Downtime. Am J Med Qual.
2017;32(5):547-551. doi:10.1177/1062860616667546.
https://psnet.ahrq.gov/issue/all-clear-preparing-it-downtime
Due to the increasing integration of health care proc…
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psnet.ahrq.gov/node/73692/psn-pdf
September 08, 2021 - Quality and safety in surgery: challenges and
opportunities.
September 8, 2021
Nasca BJ, Bilimoria KY, Yang AD. Quality and safety in surgery: challenges and opportunities. Jt Comm J
Qual Patient Saf. 2021;47(9):604-607. doi:10.1016/j.jcjq.2021.05.003.
https://psnet.ahrq.gov/issue/quality-and-safety-surgery-challe…
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psnet.ahrq.gov/node/72601/psn-pdf
January 01, 2021 - Increasing physician reporting of diagnostic learning
opportunities.
December 23, 2020
Marshall TL, Ipsaro AJ, Le M, et al. Increasing physician reporting of diagnostic learning opportunities.
Pediatrics. 2021;147(1):e20192400. doi:10.1542/peds.2019-2400.
https://psnet.ahrq.gov/issue/increasing-physician-reporting…
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psnet.ahrq.gov/node/44999/psn-pdf
August 03, 2017 - An analysis of electronic health record–related patient
safety incidents.
August 3, 2017
Palojoki S, Mäkelä M, Lehtonen L, et al. An analysis of electronic health record-related patient safety
incidents. Health Informatics J. 2017;23(2):134-145. doi:10.1177/1460458216631072.
https://psnet.ahrq.gov/issue/analysis-e…
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psnet.ahrq.gov/node/40527/psn-pdf
June 15, 2011 - Online medication error graphic reports: a pilot in North
Carolina nursing homes.
June 15, 2011
Greene SB, Williams CE, Pierson S, et al. Online medication error graphic reports: a pilot in North Carolina
nursing homes. J Patient Saf. 2011;7(2):92-8. doi:10.1097/PTS.0b013e31821b4eab.
https://psnet.ahrq.gov/issue/o…
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psnet.ahrq.gov/node/858173/psn-pdf
December 13, 2023 - Measurement of ambulatory medication errors in
children: a scoping review.
December 13, 2023
Rickey L, Auger K, Britto MT, et al. Measurement of ambulatory medication errors in children: a scoping
review. Pediatrics. 2023;152(6):e2023061281. doi:10.1542/peds.2023-061281.
https://psnet.ahrq.gov/issue/measurement-am…
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psnet.ahrq.gov/node/72581/psn-pdf
December 16, 2020 - Dispensing Errors.
December 16, 2020
Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944).
November 10, December 1, 2020.
https://psnet.ahrq.gov/issue/dispensing-errors
Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies.
Par…
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psnet.ahrq.gov/issue/missed-lesions-abdominal-oncologic-ct-lessons-learned-quality-assurance
April 21, 2011 - October 4, 2011
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/evaluation-12-strategies-obtaining-second-opinions-improve-interpretation-breast
November 03, 2015 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/characteristics-and-predictors-missed-opportunities-lung-cancer-diagnosis-electronic-health
January 19, 2012 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/diagnostic-errors-musculoskeletal-oncology-and-possible-mitigation-strategies
May 01, 2013 - December 27, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung-cancer
March 28, 2012 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/delayed-or-missed-diagnosis-cervical-spine-injuries
May 05, 2010 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/patient-safety-leadership-academy-university-pennsylvania-first-cohorts-learning-experience
October 04, 2011 - June 18, 2013
Why Current Breast Pathology Practices Must Be Evaluated.