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psnet.ahrq.gov/node/37850/psn-pdf
June 18, 2008 - Information technology-based approaches to reducing
repeat drug exposure in patients with known drug
allergies.
June 18, 2008
Cresswell K, Sheikh A. Information technology-based approaches to reducing repeat drug exposure in
patients with known drug allergies. J Allergy Clin Immunol. 2008;121(5):1112-1117.e7.
doi…
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psnet.ahrq.gov/node/72685/psn-pdf
January 27, 2021 - Human Factors and Ergonomics in Healthcare.
January 27, 2021
Carayon P, Hignett S, Albolino S eds. Int J Qual Health Care. 2021;33(Supp1):1-71.
https://psnet.ahrq.gov/issue/human-factors-and-ergonomics-healthcare
Human factors approaches have been identified as one of the primary vehicles to create las…
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psnet.ahrq.gov/node/37367/psn-pdf
May 26, 2011 - Reasons provided by prescribers when overriding
drug–drug interaction alerts.
May 26, 2011
Grizzle AJ, Mahmood MH, Ko Y, et al. Reasons provided by prescribers when overriding drug-drug
interaction alerts. Am J Manag Care. 2007;13(10):573-578.
https://psnet.ahrq.gov/issue/reasons-provided-prescribers-when-overridi…
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psnet.ahrq.gov/node/38824/psn-pdf
March 04, 2011 - Evaluation of a physician informatics tool to improve
patient handoffs.
March 4, 2011
Flanagan ME, Patterson ES, Frankel RM, et al. Evaluation of a physician informatics tool to improve patient
handoffs. J Am Med Inform Assoc. 2009;16(4):509-15. doi:10.1197/jamia.M2892.
https://psnet.ahrq.gov/issue/evaluation-phys…
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psnet.ahrq.gov/node/39751/psn-pdf
August 11, 2010 - Interpreting adverse drug reaction (ADR) reports as
hospital patient safety incidents.
August 11, 2010
Davies EC, Green CF, Mottram DR, et al. Interpreting adverse drug reaction (ADR) reports as hospital
patient safety incidents. Br J Clin Pharmacol. 2010;70(1):102-8. doi:10.1111/j.1365-2125.2010.03671.x.
https://…
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psnet.ahrq.gov/node/37920/psn-pdf
May 24, 2015 - Functional health literacy and understanding of
medications at discharge.
May 24, 2015
Maniaci MJ, Heckman MG, Dawson NL. Functional health literacy and understanding of medications at
discharge. Mayo Clin Proc. 2008;83(5):554-8. doi:10.4065/83.5.554.
https://psnet.ahrq.gov/issue/functional-health-literacy-and-und…
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psnet.ahrq.gov/node/46385/psn-pdf
October 23, 2018 - The key to reducing doctors' misdiagnoses.
October 23, 2018
Landro L. Wall Street Journal. September 12, 2017.
https://psnet.ahrq.gov/issue/key-reducing-doctors-misdiagnoses
Misdiagnosis has gained recognition as an important patient safety problem. This newspaper article reports
on several areas of research and i…
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psnet.ahrq.gov/node/44097/psn-pdf
June 10, 2015 - Hospital nurses' perceptions of human factors
contributing to nursing errors.
June 10, 2015
Roth C, Wieck L, Fountain R, et al. Hospital nurses' perceptions of human factors contributing to nursing
errors. J Nurs Adm. 2015;45(5):263-9. doi:10.1097/NNA.0000000000000196.
https://psnet.ahrq.gov/issue/hospital-nurses-…
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psnet.ahrq.gov/node/40713/psn-pdf
August 24, 2011 - Medication reconciliation: barriers and facilitators from
the perspectives of resident physicians and pharmacists.
August 24, 2011
Boockvar KS, Santos SL, Kushniruk AW, et al. Medication reconciliation: Barriers and facilitators from the
perspectives of resident physicians and pharmacists. J Hosp Med. 2011;6(6). do…
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psnet.ahrq.gov/node/45450/psn-pdf
February 13, 2018 - Avoiding Unconscious Bias: a Guide for Surgeons.
February 13, 2018
London, UK: Royal College of Surgeons of England; 2016.
https://psnet.ahrq.gov/issue/avoiding-unconscious-bias-guide-surgeons
Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides
information for sur…
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psnet.ahrq.gov/node/41098/psn-pdf
March 04, 2015 - Automated identification of extreme-risk events in clinical
incident reports.
March 4, 2015
Ong M-S, Magrabi F, Coiera E. Automated identification of extreme-risk events in clinical incident reports. J
Am Med Inform Assoc. 2012;19(e1):e110-8.
https://psnet.ahrq.gov/issue/automated-identification-extreme-risk-event…
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psnet.ahrq.gov/node/47791/psn-pdf
March 20, 2019 - Essential activities for electronic health record safety: a
qualitative study.
March 20, 2019
Ash JS, Singh H, Wright A, et al. Essential activities for electronic health record safety: A qualitative study.
Health Informatics J. 2019:1460458219833109. doi:10.1177/1460458219833109.
https://psnet.ahrq.gov/issue/esse…
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psnet.ahrq.gov/node/37338/psn-pdf
January 02, 2017 - Using the rapid response system to provide better
oversight of patient care processes.
January 2, 2017
Moore MS, Howard SK, Lighthall GK. Using the rapid response system to provide better oversight of
patient care processes. Jt Comm J Qual Patient Saf. 2007;33(11):695-8, 645.
https://psnet.ahrq.gov/issue/using-rap…
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psnet.ahrq.gov/node/60741/psn-pdf
July 29, 2020 - As college students return, a crisis in campus care
awaits.
July 29, 2020
Abelson J, Tran AB, Kornfield M, et al. As college students return, a crisis in campus care awaits. The
Seattle Times. 2020;July 13.
https://psnet.ahrq.gov/issue/college-students-return-crisis-campus-care-awaits
The COVID-19 pandemic has im…
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psnet.ahrq.gov/node/38920/psn-pdf
January 03, 2017 - How improving practice relationships among clinicians
and nonclinicians can improve quality in primary care.
January 3, 2017
Lanham H, McDaniel RR, Crabtree B, et al. How improving practice relationships among clinicians and
nonclinicians can improve quality in primary care. Jt Comm J Qual Patient Saf. 2009;35(9):4…
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psnet.ahrq.gov/node/39050/psn-pdf
January 04, 2010 - Safety as a criterion for quality: The Critical Nursing
Situation Index in paediatric critical care, an observational
study.
January 4, 2010
de Neef M, Bos AP, Tol D. Safety as a criterion for quality: the critical nursing situation index in paediatric
critical care, an observational study. Intensive Crit Care Nur…
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psnet.ahrq.gov/node/38637/psn-pdf
September 24, 2016 - Work interruptions and their contribution to medication
administration errors: an evidence review.
September 24, 2016
Biron AD, Loiselle CG, Lavoie-Tremblay M. Work interruptions and their contribution to medication
administration errors: an evidence review. Worldviews Evid Based Nurs. 2009;6(2):70-86.
doi:10.1111…
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psnet.ahrq.gov/node/43790/psn-pdf
October 23, 2023 - Complaints to the Parliamentary and Health Service
Ombudsman.
October 23, 2023
Manchester, UK: Parliamentary and Health Service Ombudsman.
https://psnet.ahrq.gov/issue/complaints-about-acute-trusts-2016-2017
The National Health Service broadly reports the results of system-level analyses and investigations into
t…
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psnet.ahrq.gov/node/35304/psn-pdf
July 14, 2009 - Medication error in the care of HIV/AIDS patients:
electronic surveillance, confirmation, and adverse events.
July 14, 2009
DeLorenze GN, Follansbee SF, Nguyen DP, et al. Medication error in the care of HIV/AIDS patients:
electronic surveillance, confirmation, and adverse events. Med Care. 2005;43(9 Suppl):III63-II…
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psnet.ahrq.gov/node/41896/psn-pdf
December 12, 2012 - Bar-code verification: reducing but not eliminating
medication errors.
December 12, 2012
Henneman PL, Marquard J, Fisher DL, et al. Bar-code verification: reducing but not eliminating medication
errors. J Nurs Adm. 2012;42(12):562-6. doi:10.1097/NNA.0b013e318274b545.
https://psnet.ahrq.gov/issue/bar-code-verificat…