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psnet.ahrq.gov/node/47955/psn-pdf
April 17, 2019 - Will human factors restore faith in the GMC?
April 17, 2019
Morgan L, Benson D, McCulloch P. Will human factors restore faith in the GMC? BMJ. 2019;364:l1037.
doi:10.1136/bmj.l1037.
https://psnet.ahrq.gov/issue/will-human-factors-restore-faith-gmc
Investigations into medical mistakes that result in patient harm sh…
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psnet.ahrq.gov/node/34748/psn-pdf
March 07, 2005 - Reducing Adverse Drug Events.
March 7, 2005
Leape LL, Kabcenell A, Berwick DM et al. Boston, MA: Institute for Healthcare Improvement; 1998.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-events
This application-oriented book provides the results of the Institute for Healthcare Improvement (IHI)
Breakthrough S…
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psnet.ahrq.gov/node/34726/psn-pdf
April 19, 2011 - How house officers cope with their mistakes.
April 19, 2011
Wu AW, Folkman S, McPhee SJ, et al. How house officers cope with their mistakes. West J Med.
1993;159(5):565-569.
https://psnet.ahrq.gov/issue/how-house-officers-cope-their-mistakes
In this article, the authors report on how house officers cope with their…
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psnet.ahrq.gov/node/46592/psn-pdf
December 19, 2017 - The evolution of procedural competency in internal
medicine training.
December 19, 2017
Sacks CA, Alba GA, Miloslavsky EM. The Evolution of Procedural Competency in Internal Medicine
Training. JAMA Intern Med. 2017;177(12):1713-1714. doi:10.1001/jamainternmed.2017.5014.
https://psnet.ahrq.gov/issue/evolution-proce…
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psnet.ahrq.gov/node/44126/psn-pdf
May 13, 2015 - SAFER Electronic Health Records: Safety Assurance
Factors for EHR Resilience.
May 13, 2015
Sittig DF, Singh H, eds. Waretown, NJ: Apple Academic Press; 2015. ISBN: 9781771881173.
https://psnet.ahrq.gov/issue/safer-electronic-health-records-safety-assurance-factors-ehr-resilience
Implementation of electronic health…
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psnet.ahrq.gov/node/43181/psn-pdf
May 14, 2014 - Overextended: fighting the fatigue of long shifts.
May 14, 2014
Douglass JA. Overextended: Fighting the fatigue of long shifts. Nursing (Brux). 2014;44(3):67-8.
doi:10.1097/01.NURSE.0000441895.42899.0c.
https://psnet.ahrq.gov/issue/overextended-fighting-fatigue-long-shifts
Many studies have demonstrated the link b…
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psnet.ahrq.gov/node/43335/psn-pdf
July 09, 2014 - Wake Up Safe and root cause analysis: quality
improvement in pediatric anesthesia.
July 9, 2014
Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in
pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.0000000000000266.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/45549/psn-pdf
October 12, 2016 - Preventing diagnostic errors in primary care.
October 12, 2016
Ely JW, Graber ML. Preventing Diagnostic Errors in Primary Care. Am Fam Physician. 2016;94(6):426-32.
https://psnet.ahrq.gov/issue/preventing-diagnostic-errors-primary-care
The Improving Diagnosis in Health Care report advocated for enhancing patient en…
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psnet.ahrq.gov/node/40168/psn-pdf
December 21, 2014 - Variation in surgical time-out and site marking within
pediatric otolaryngology.
December 21, 2014
Shah RK, Arjmand E, Roberson DW, et al. Variation in surgical time-out and site marking within pediatric
otolaryngology. Arch Otolaryngol Head Neck Surg. 2011;137(1):69-73. doi:10.1001/archoto.2010.232.
https://psnet…
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psnet.ahrq.gov/node/74019/psn-pdf
July 11, 2023 - PACT Collaborative: Pathway to Accountability,
Compassion and Transparency.
July 11, 2023
Ariadne Labs, Brigham and Women’s Hospital, Harvard TH Chan School of Public Health.
https://psnet.ahrq.gov/issue/pact-collaborative-pathway-accountability-compassion-and-transparency
Communication and Resolution Programs (CR…
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psnet.ahrq.gov/node/852804/psn-pdf
August 23, 2023 - Five new ways to advance diagnostic safety in your
clinical practice.
August 23, 2023
Bradford A, Goeschel C, Shofer M, et al. Am Fam Physician. 2023;108(1):14-16.
https://psnet.ahrq.gov/issue/five-new-ways-advance-diagnostic-safety-your-clinical-practice
Diagnostic errors are common in the ambulatory environment.…
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psnet.ahrq.gov/node/48167/psn-pdf
August 28, 2019 - ASHP guidelines on perioperative pharmacy services.
August 28, 2019
Bickham P, Golembiewski J, Meyer T, et al. ASHP guidelines on perioperative pharmacy services. Am J
Health Syst Pharm. 2019;76(12):903-820. doi:10.1093/ajhp/zxz073.
https://psnet.ahrq.gov/issue/ashp-guidelines-perioperative-pharmacy-services
Pharm…
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psnet.ahrq.gov/node/46367/psn-pdf
August 30, 2017 - Why are so many women being misdiagnosed?
August 30, 2017
Mickle K. Glamour. August 11, 2017.
https://psnet.ahrq.gov/issue/why-are-so-many-women-being-misdiagnosed
Implicit bias and differences in communication style can affect patient care. This magazine article reports
on factors that contribute to misdiagnosis …
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psnet.ahrq.gov/node/48041/psn-pdf
July 10, 2019 - Accuracy of computer-aided diagnosis of melanoma: a
meta-analysis.
July 10, 2019
Dick V, Sinz C, Mittlböck M, et al. Accuracy of Computer-Aided Diagnosis of Melanoma. JAMA Dermatol.
2019;155(11):1291-1299. doi:10.1001/jamadermatol.2019.1375.
https://psnet.ahrq.gov/issue/accuracy-computer-aided-diagnosis-melanoma-m…
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psnet.ahrq.gov/node/40199/psn-pdf
March 03, 2011 - Perspective: malpractice in an academic medical center: a
frequently overlooked aspect of professionalism
education.
March 3, 2011
Hochberg MS, Seib CD, Berman RS, et al. Perspective: Malpractice in an academic medical center: a
frequently overlooked aspect of professionalism education. Acad Med. 2011;86(3):365-8.…
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psnet.ahrq.gov/node/46636/psn-pdf
January 24, 2018 - Drug shortages continue to compromise patient care.
January 24, 2018
ISMP Medication Safety Alert! Acute Care Edition. January 11, 2018;23:1-4.
https://psnet.ahrq.gov/issue/drug-shortages-continue-compromise-patient-care
Drug shortages are known to disrupt the safety of care. This newsletter article reports the res…
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psnet.ahrq.gov/node/848825/psn-pdf
May 10, 2023 - Laura Levis' death outside ER has changed hospital
signage, lighting in Mass.
May 10, 2023
Mullins L, Menard F. WBUR. April 27, 2023.
https://psnet.ahrq.gov/issue/laura-levis-death-outside-er-has-changed-hospital-signage-lighting-mass
Incomplete information and building design problems can reduce access to care an…
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psnet.ahrq.gov/node/44442/psn-pdf
August 26, 2015 - How your hospital can make you sick.
August 26, 2015
Consumer Reports. July 29, 2015.
https://psnet.ahrq.gov/issue/how-your-hospital-can-make-you-sick
This news article reports on health care–associated infections, particularly Clostridium difficile and
methicillin-resistant Staphylococcus aureus, discusses ways h…
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psnet.ahrq.gov/node/44243/psn-pdf
November 09, 2015 - Concept analysis: wrong-site surgery.
November 9, 2015
Watson DS. Concept analysis: wrong-site surgery. AORN J. 2015;101(6):650-6.
doi:10.1016/j.aorn.2015.03.012.
https://psnet.ahrq.gov/issue/concept-analysis-wrong-site-surgery
Despite large-scale efforts to prevent wrong-site surgeries, they continue to occur. Th…
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psnet.ahrq.gov/node/844771/psn-pdf
September 11, 2019 - Raising and responding to frontline concerns in
healthcare.
September 11, 2019
Mannion R, Davies H. Raising and responding to frontline concerns in healthcare. BMJ. 2019;366:l4944.
doi:10.1136/bmj.l4944.
https://psnet.ahrq.gov/issue/raising-and-responding-frontline-concerns-healthcare
Psychological safety empower…