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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - A quality improvement program in the Veterans Affairs system that incorporated the above principles
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psnet.ahrq.gov/node/837330/psn-pdf
June 08, 2022 - A call to action: next steps to advance diagnosis
education in the health professions.
June 8, 2022
Graber ML, Holmboe ES, Stanley J, et al. A call to action: next steps to advance diagnosis education in the
health professions. Diagnosis (Berl). 2022;9(2):166-175. doi:10.1515/dx-2021-0103.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/50916/psn-pdf
February 19, 2020 - Patient safety and suicide prevention in mental health
services: time for a new paradigm?
February 19, 2020
Quinlivan L, Littlewood DL, Webb RT, et al. Patient safety and suicide prevention in mental health services:
time for a new paradigm? J Mental Health. 2020;29(1):1-5. doi:10.1080/09638237.2020.1714013.
https…
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psnet.ahrq.gov/node/50922/psn-pdf
February 19, 2020 - An Organisation Losing its Memory? Patient Safety
Alerts: Implementation, Monitoring and Regulation in
England
February 19, 2020
Cousins D. Croydon, UK: Accidents against Medical Accidents; 2020.
https://psnet.ahrq.gov/issue/organisation-losing-its-memory-patient-safety-alerts-implementation-
monitoring-and-regul…
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psnet.ahrq.gov/node/47773/psn-pdf
April 17, 2019 - People, systems and safety: resilience and excellence in
healthcare practice.
April 17, 2019
Smith AF, Plunkett E. People, systems and safety: resilience and excellence in healthcare practice.
Anaesthesia. 2019;74(4):508-517. doi:10.1111/anae.14519.
https://psnet.ahrq.gov/issue/people-systems-and-safety-resilience…
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psnet.ahrq.gov/node/41970/psn-pdf
July 02, 2014 - Transformative learning in a professional development
course aimed at addressing disruptive physician
behavior: a composite case study.
July 2, 2014
Samenow CP, Worley LLM, Neufeld R, et al. Transformative learning in a professional development course
aimed at addressing disruptive physician behavior: a composite …
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psnet.ahrq.gov/node/43457/psn-pdf
August 02, 2015 - A human factors subsystems approach to trauma care.
August 2, 2015
Catchpole K, Ley EJ, Wiegmann D, et al. A human factors subsystems approach to trauma care. JAMA
Surg. 2014;149(9):962-8.
https://psnet.ahrq.gov/issue/human-factors-subsystems-approach-trauma-care
Human factors analysis led to five system changes i…
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psnet.ahrq.gov/node/42929/psn-pdf
February 05, 2014 - Do no harm: is it time to rethink the Hippocratic Oath?
February 5, 2014
Walton M, Kerridge I. Do no harm: is it time to rethink the Hippocratic Oath? Med Educ. 2014;48(1):17-27.
doi:10.1111/medu.12275.
https://psnet.ahrq.gov/issue/do-no-harm-it-time-rethink-hippocratic-oath
This commentary discusses how health ca…
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psnet.ahrq.gov/node/44016/psn-pdf
November 21, 2016 - Partnering to Improve Quality and Safety: A Framework
for Working With Patient and Family Advisors.
November 21, 2016
Chicago, IL: Health Research & Educational Trust; 2015.
https://psnet.ahrq.gov/issue/partnering-improve-quality-and-safety-framework-working-patient-and-family-
advisors
Patient and family advisor…
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psnet.ahrq.gov/node/39886/psn-pdf
April 17, 2013 - Nurse/physician communication through a sensemaking
lens: shifting the paradigm to improve patient safety.
April 17, 2013
Manojlovich M. Nurse/physician communication through a sensemaking lens: shifting the paradigm to
improve patient safety. Med Care. 2010;48(11):941-6. doi:10.1097/MLR.0b013e3181eb31bd.
https://…
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psnet.ahrq.gov/node/44684/psn-pdf
November 18, 2015 - Preventing medication errors by empowering patients.
November 18, 2015
Karch AM. Am Nurs Today. September 2015;10:18-22.
https://psnet.ahrq.gov/issue/preventing-medication-errors-empowering-patients
The complexity of care delivery can hinder the role of nurses in preventing medication errors. This
commentary advoc…
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psnet.ahrq.gov/node/42649/psn-pdf
October 09, 2013 - Spreading human factors expertise in healthcare:
untangling the knots in people and systems.
October 9, 2013
Catchpole K. Spreading human factors expertise in healthcare: untangling the knots in people and
systems. BMJ Qual Saf. 2013;22(10):793-7. doi:10.1136/bmjqs-2013-002036.
https://psnet.ahrq.gov/issue/spreadi…
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psnet.ahrq.gov/node/48087/psn-pdf
July 10, 2019 - The rise of human factors: optimising performance of
individuals and teams to improve patients' outcomes.
July 10, 2019
Casali G, Cullen W, Lock G. The rise of human factors: optimising performance of individuals and teams to
improve patients' outcomes. J Thorac Dis. 2019;11(Suppl 7):S998-S1008. doi:10.21037/jtd.20…
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psnet.ahrq.gov/node/73165/psn-pdf
April 21, 2021 - Recommendations for the safe, effective use of adaptive
CDS in the US healthcare system: an AMIA position
paper.
April 21, 2021
Petersen C, Smith J, Freimuth RR, et al. Recommendations for the safe, effective use of adaptive CDS in
the US healthcare system: an AMIA position paper. J Amer Med Inform Assoc. 2020;28(…
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psnet.ahrq.gov/node/866735/psn-pdf
September 18, 2024 - Achieving diagnostic excellence: roadmaps to develop
and use patient-reported measures with an equity lens.
September 18, 2024
McDonald KM, Gleason KT, Jajodia A, et al. Achieving diagnostic excellence: roadmaps to develop and
use patient-reported measures with an equity lens. Int J Health Policy Manag. 2024;13:804…
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psnet.ahrq.gov/node/42955/psn-pdf
May 11, 2016 - National Patient Safety Alerting System.
May 11, 2016
National Health Service England
https://psnet.ahrq.gov/issue/national-patient-safety-alerting-system
In response to the Francis report, this three-stage reporting system was launched to help National Health
Service organizations learn from incidents and incorpo…
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psnet.ahrq.gov/node/50919/psn-pdf
October 03, 2013 - SEIPS 2.0: a human factors framework for studying and
improving the work of healthcare professionals and
patients.
October 3, 2013
Holden RJ, Carayon P, Gurses AP, et al. SEIPS 2.0: a human factors framework for studying and
improving the work of healthcare professionals and patients. Ergonomics. 2013;56(11):1669-…
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psnet.ahrq.gov/node/35339/psn-pdf
April 23, 2014 - Disclosing harmful medical errors to patients: a time for
professional action.
April 23, 2014
Gallagher TH, Levinson W. Disclosing Harmful Medical Errors to Patients. Arch Intern Med. 2005;165(16).
doi:10.1001/archinte.165.16.1819.
https://psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-time-profes…
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psnet.ahrq.gov/node/41781/psn-pdf
October 24, 2012 - Designing for Patient Safety: Developing Methods to
Integrate Patient Safety Concerns in the Design Process.
October 24, 2012
Joseph A, Quan X, Taylor E, Jelen M. Concord, CA: Center for Health Design; 2012.
https://psnet.ahrq.gov/issue/designing-patient-safety-developing-methods-integrate-patient-safety-
co…
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psnet.ahrq.gov/node/47320/psn-pdf
September 05, 2018 - Patient safety climate: a study of Southern California
healthcare organizations.
September 5, 2018
Avramchuk AS, McGuire SJJ. Patient Safety Climate: A Study of Southern California Healthcare
Organizations. J Healthc Manag. 2018;63(3):175-192. doi:10.1097/JHM-D-16-00004.
https://psnet.ahrq.gov/issue/patient-safety…