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psnet.ahrq.gov/node/47892/psn-pdf
March 27, 2019 - Addressing medicine's bias against patients who are
overweight.
March 27, 2019
Rubin R. Addressing Medicine's Bias Against Patients Who Are Overweight. JAMA. 2019;321(10):925-927.
doi:10.1001/jama.2019.0048.
https://psnet.ahrq.gov/issue/addressing-medicines-bias-against-patients-who-are-overweight
Patients with o…
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psnet.ahrq.gov/node/73429/psn-pdf
June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures
in Outpatient Settings.
June 23, 2021
Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
Wrong site/wrong patent surgery is a persisten…
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psnet.ahrq.gov/node/45904/psn-pdf
October 24, 2017 - Addressing physician burnout: the way forward.
October 24, 2017
Shanafelt TD, Dyrbye LN, West CP. Addressing Physician Burnout: The Way Forward. JAMA.
2017;317(9):901-902. doi:10.1001/jama.2017.0076.
https://psnet.ahrq.gov/issue/addressing-physician-burnout-way-forward
Burnout can diminish both patient safety and …
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psnet.ahrq.gov/node/36511/psn-pdf
January 07, 2011 - Facing ambiguous threats.
January 7, 2011
Roberto MA, Bohmer RMJ, Edmondson A. Facing ambiguous threats. Harv Bus Rev. 2006;84(11):106-13,
157.
https://psnet.ahrq.gov/issue/facing-ambiguous-threats
This study describes how organizations respond to signs that may or may not portend future
catastrophes. The authors…
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psnet.ahrq.gov/node/43390/psn-pdf
July 30, 2014 - Hazards tied to medical records rush.
July 30, 2014
Rowland C.
https://psnet.ahrq.gov/issue/hazards-tied-medical-records-rush
Government incentives have led to rapid development and adoption of electronic health records (EHRs).
This newspaper article examines some of the unintended consequences of implementing ele…
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psnet.ahrq.gov/node/840163/psn-pdf
November 16, 2022 - Deep Dive: Racial and Ethnic Disparities in Health and
Healthcare.
November 16, 2022
Plymouth Meeting, PA: ECRI and the Institute for Safe Medication Practices; 2022.
https://psnet.ahrq.gov/issue/deep-dive-racial-and-ethnic-disparities-health-and-healthcare
Racist behavior directed at either patients or clinicians…
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psnet.ahrq.gov/node/44431/psn-pdf
October 21, 2015 - Use of a human factors classification framework to
identify causal factors for medication and medical device-
related adverse clinical incidents.
October 21, 2015
Mitchell RJ, Williamson A, Molesworth B. Use of a human factors classification framework to identify causal
factors for medication and medical device-re…
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psnet.ahrq.gov/node/46697/psn-pdf
January 10, 2018 - Primary care providers' perspectives on errors of
omission.
January 10, 2018
Poghosyan L, Norful AA, Fleck E, et al. Primary Care Providers' Perspectives on Errors of Omission. J Am
Board Fam Med. 2017;30(6):733-742. doi:10.3122/jabfm.2017.06.170161.
https://psnet.ahrq.gov/issue/primary-care-providers-perspectives…
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psnet.ahrq.gov/node/854992/psn-pdf
November 01, 2023 - Failure to rescue as a patient safety indicator for
neurosurgical patients: are we there yet?
November 1, 2023
Roy JM, Rumalla K, Skandalakis GP, et al. Failure to rescue as a patient safety indicator for neurosurgical
patients: are we there yet? A systematic review. Neurosurg Rev. 2023;46(1):227. doi:10.1007/s1014…
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psnet.ahrq.gov/node/60797/psn-pdf
August 12, 2020 - Nonoperating room anaesthesia: safety, monitoring,
cognitive aids and severe acute respiratory syndrome
coronavirus 2.
August 12, 2020
Borshoff DC, Sadleir P. Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe
acute respiratory syndrome coronavirus 2. Curr Opin Anaesthesiol. 2020;33(4):55…
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psnet.ahrq.gov/node/48028/psn-pdf
August 28, 2019 - Error Reduction and Prevention in Surgical Pathology,
Second Edition.
August 28, 2019
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
https://psnet.ahrq.gov/issue/error-reduction-and-prevention-surgical-pathology-2nd-edition
Surgical specimen and laboratory process proble…
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psnet.ahrq.gov/node/44989/psn-pdf
July 01, 2016 - Can medical record reviewers reliably identify errors and
adverse events in the ED?
July 1, 2016
Klasco RS, Wolfe RE, Lee T, et al. Can medical record reviewers reliably identify errors and adverse
events in the ED? Am J Emerg Med. 2016;34(6):1043-8. doi:10.1016/j.ajem.2016.03.001.
https://psnet.ahrq.gov/issue/can…
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psnet.ahrq.gov/node/37769/psn-pdf
March 10, 2011 - Turning off frequently overridden drug alerts: limited
opportunities for doing it safely.
March 10, 2011
van der Sijs H, Aarts J, van Gelder T, et al. Turning off frequently overridden drug alerts: limited
opportunities for doing it safely. J Am Med Inform Assoc. 2008;15(4):439-48. doi:10.1197/jamia.M2311.
https:/…
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psnet.ahrq.gov/node/46287/psn-pdf
April 12, 2019 - Anesthesia adverse events voluntarily reported in the
Veterans Health Administration and lessons learned.
April 12, 2019
Neily J, Silla ES, Sum-Ping S (J) T, et al. Anesthesia Adverse Events Voluntarily Reported in the Veterans
Health Administration and Lessons Learned. Anesth Analg. 2017;126(2):471-477.
doi:10.12…
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psnet.ahrq.gov/node/47623/psn-pdf
February 06, 2019 - Diagnostic heuristics in dermatology—part 1 and part 2.
February 6, 2019
Lowenstein EJ, Sidlow R. Cognitive and visual diagnostic errors in dermatology: part 1 and part 2. J
Dermatol. 2018;179(6):1263-1276. doi:10.1111/bjd.16932.
https://psnet.ahrq.gov/issue/diagnostic-heuristics-dermatology-part-1-and-part-2
Cogn…
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psnet.ahrq.gov/node/867144/psn-pdf
November 13, 2024 - Life of the Mother. How Abortion Bans Lead to
Preventable Deaths.
November 13, 2024
Jaramillo C, Surana K, Presser L, et al. Life of the Mother. How Abortion Bans Lead to Preventable Deaths.
ProPublica. 2024:September - November 2024.
https://psnet.ahrq.gov/issue/life-mother-how-abortion-bans-lead-preventable-deat…
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psnet.ahrq.gov/node/44285/psn-pdf
November 06, 2015 - Hospital board oversight of quality and safety: a
stakeholder analysis exploring the role of trust and
intelligence.
November 6, 2015
Millar R, Freeman T, Mannion R. Hospital board oversight of quality and safety: a stakeholder analysis
exploring the role of trust and intelligence. BMC Health Serv Res. 2015;15:196…
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psnet.ahrq.gov/node/44674/psn-pdf
December 18, 2017 - Achieving Safe Health Care: Delivery of Safe Patient Care
at Baylor Scott & White Health.
December 18, 2017
Compton J. Boca Raton, FL: CRC Press; 2016. ISBN: 9781498732390.
https://psnet.ahrq.gov/issue/achieving-safe-health-care-delivery-safe-patient-care-baylor-scott-white-health
Since the publication of the Inst…
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psnet.ahrq.gov/node/35237/psn-pdf
November 29, 2009 - Improving nurse-to-patient staffing ratios as a cost-
effective safety intervention.
November 29, 2009
Rothberg MB, Abraham I, Lindenauer PK, et al. Improving nurse-to-patient staffing ratios as a cost-effective
safety intervention. Med Care. 2005;43(8):785-91.
https://psnet.ahrq.gov/issue/improving-nurse-patient-…
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psnet.ahrq.gov/node/47852/psn-pdf
May 08, 2019 - Impact of time pressure on dentists' diagnostic
performance.
May 8, 2019
Plessas A, Nasser M, Hanoch Y, et al. Impact of time pressure on dentists' diagnostic performance. J Dent.
2019;82:38-44. doi:10.1016/j.jdent.2019.01.011.
https://psnet.ahrq.gov/issue/impact-time-pressure-dentists-diagnostic-performance
This…