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psnet.ahrq.gov/node/36370/psn-pdf
June 12, 2013 - Health Information Technology in the United States: The
Information Base for Progress.
June 12, 2013
Blumenthal D, DesRoches C, Donelan K, et al. Princeton, NJ: Robert Wood Johnson Foundation; 2006.
https://psnet.ahrq.gov/issue/health-information-technology-united-states-information-base-progress
This report share…
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psnet.ahrq.gov/issue/informal-learning-error-hospitals-what-do-we-learn-how-do-we-learn-and-how-can-informal
March 14, 2012 - Review
Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning be enhanced? A narrative review.
Citation Text:
de Feijter JM, de Grave WS, Koopmans RP, et al. Informal learning from error in hospitals: what do we learn, how do we learn…
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psnet.ahrq.gov/issue/automated-identification-extreme-risk-events-clinical-incident-reports
November 03, 2015 - Study
Automated identification of extreme-risk events in clinical incident reports.
Citation Text:
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.
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Format:
Go…
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psnet.ahrq.gov/issue/challenges-ethics-safety-best-practices-and-oversight-regarding-hit-vendors-their-customers
July 30, 2014 - Commentary
Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: a report of an AMIA special task force.
Citation Text:
Goodman KW, Berner ES, Dente MA, et al. Challenges in ethics, safety, best practices, and oversight regard…
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psnet.ahrq.gov/issue/improving-end-life-care-information-systems-approach-reducing-medical-errors
November 04, 2015 - Study
Improving end of life care: an information systems approach to reducing medical errors.
Citation Text:
Tamang S, Kopec D, Shagas G, et al. Improving end of life care: an information systems approach to reducing medical errors. Stud Health Technol Inform. 2005;114:93-104.
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psnet.ahrq.gov/issue/role-personal-health-information-management-promoting-patient-safety-home-qualitative
June 15, 2022 - Study
The role of personal health information management in promoting patient safety in the home: a qualitative analysis
Citation Text:
Demiris G, Lin S-Y, Turner AM. The role of personal health information management in promoting patient safety in the home: a qualitative analysis. Stud …
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psnet.ahrq.gov/node/45057/psn-pdf
June 22, 2017 - Safety risks associated with the lack of integration and
interfacing of hospital health information technologies: a
qualitative study of hospital electronic prescribing
systems in England.
June 22, 2017
Cresswell K, Mozaffar H, Lee L, et al. Safety risks associated with the lack of integration and interfacing of
…
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psnet.ahrq.gov/node/852273/psn-pdf
August 09, 2023 - Experimental evidence for structured information-sharing
networks reducing medical errors.
August 9, 2023
Centola D, Becker J, Zhang J, et al. Experimental evidence for structured information–sharing networks
reducing medical errors. Proc Natl Acad Sci U S A. 2023;120(31):e2108290120.
doi:10.1073/pnas.2108290120.
…
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psnet.ahrq.gov/node/44672/psn-pdf
October 11, 2017 - Identifying patient safety problems associated with
information technology in general practice: an analysis of
incident reports.
October 11, 2017
Magrabi F, Liaw ST, Arachi D, et al. Identifying patient safety problems associated with information
technology in general practice: an analysis of incident reports. BMJ…
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psnet.ahrq.gov/node/47195/psn-pdf
September 12, 2018 - Diagnostic discordance, health information exchange,
and inter-hospital transfer outcomes: a population study.
September 12, 2018
Usher M, Sahni N, Herrigel D, et al. Diagnostic discordance, health information exchange, and inter-
hospital transfer outcomes: a population study. J Gen Intern Med. 2018;33(9):1447-145…
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psnet.ahrq.gov/node/73440/psn-pdf
June 30, 2021 - Bridging the feedback gap: a sociotechnical approach to
informing clinicians of patients' subsequent clinical
course and outcomes.
June 30, 2021
Cifra CL, Sittig DF, Singh H. Bridging the feedback gap: a sociotechnical approach to informing clinicians of
patients’ subsequent clinical course and outcomes. BMJ Qual …
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psnet.ahrq.gov/node/38309/psn-pdf
December 23, 2016 - Safely implementing health information and converging
technologies.
December 23, 2016
Safely implementing health information and converging technologies. Sentinel event alert. 2008;(42):1-4.
https://psnet.ahrq.gov/issue/safely-implementing-health-information-and-converging-technologies
As health information techno…
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psnet.ahrq.gov/node/47349/psn-pdf
January 30, 2019 - Relationship of staff information sharing and advice
networks to patient safety outcomes.
January 30, 2019
Brewer BB, Carley KM, Benham-Hutchins MM, et al. Relationship of Staff Information Sharing and Advice
Networks to Patient Safety Outcomes. J Nurs Adm. 2018;48(9):437-444.
doi:10.1097/NNA.0000000000000646.
ht…
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psnet.ahrq.gov/node/72817/psn-pdf
March 10, 2021 - Assessment of patients' ability to review electronic health
record information to identify potential errors: cross-
sectional web-based survey.
March 10, 2021
Freise L, Neves AL, Flott K, et al. Assessment of patients' ability to review electronic health record
information to identify potential errors: cross-secti…
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psnet.ahrq.gov/node/34879/psn-pdf
February 03, 2011 - Missing clinical information during primary care visits.
February 3, 2011
Smith PC, Araya-Guerra R, Bublitz C, et al. Missing clinical information during primary care visits. JAMA.
2005;293(5):565-71.
https://psnet.ahrq.gov/issue/missing-clinical-information-during-primary-care-visits
This survey of 253 primary ca…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
October 01, 2008 - Spotlight Case July 2008
Spotlight Case
Recurrent Hypoglycemia:
A Care Transition Failure?
*
*
Source and Credits
This presentation is based on the October 2008 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Ted Eytan, MD, MS, MPH
Editor, …
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psnet.ahrq.gov/node/42213/psn-pdf
April 17, 2013 - Quality: performance improvement, teamwork,
information technology and protocols.
April 17, 2013
Coleman NE, Pon S. Quality: performance improvement, teamwork, information technology and protocols.
Crit Care Clin. 2013;29(2):129-51. doi:10.1016/j.ccc.2012.11.002.
https://psnet.ahrq.gov/issue/quality-performance-im…
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psnet.ahrq.gov/node/42501/psn-pdf
January 07, 2015 - Syndromic surveillance for health information system
failures: a feasibility study.
January 7, 2015
Ong M-S, Magrabi F, Coiera E. Syndromic surveillance for health information system failures: a feasibility
study. J Am Med Inform Assoc. 2013;20(3):506-12. doi:10.1136/amiajnl-2012-001144.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - Falling Between the Cracks in the Software
Citation Text:
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - Reconciling Records
November 1, 2010
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/reconciling-records
The Cases
Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local
teaching hospital. When discharged, h…