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psnet.ahrq.gov/node/35715/psn-pdf
February 15, 2006 - Changes in intensive care unit nurse task activity after
installation of a third-generation intensive care unit
information system.
February 15, 2006
Wong DH; Gallegos Y; Weinger MB; Clack S; Slagle J; Anderson CT.
https://psnet.ahrq.gov/issue/changes-intensive-care-unit-nurse-task-activity-after-installation-thir…
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psnet.ahrq.gov/node/60586/psn-pdf
June 10, 2020 - Ensuring Healthcare Safety Throughout the COVID-19
Pandemic.
June 10, 2020
US Health and Human Services Office of the Assistant Secretary for Preparedness and Response’s
Technical Resources, Assistance Center, & Information Exchange; US Health and Human
Services/FEMA COVID-19 Healthcare Resilience Task Fo…
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psnet.ahrq.gov/node/38213/psn-pdf
November 12, 2008 - AHRQ announces interest in research on diagnostic
errors in ambulatory care settings.
November 12, 2008
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 25, 2007.
Publication No. NOT-HS-08-002.
https://psnet.ahrq.gov/issue/ahrq-announces-interest-research-diagnostic-error…
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psnet.ahrq.gov/node/44565/psn-pdf
October 14, 2015 - How to use online clinician rating systems.
October 14, 2015
Razmaria AA, Livingston EH. JAMA PATIENT PAGE. How to Use Online Clinician Rating Systems. JAMA.
2015;314(13):1418. doi:10.1001/jama.2015.11957.
https://psnet.ahrq.gov/issue/how-use-online-clinician-rating-systems
Clinician rating sites may not always pr…
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psnet.ahrq.gov/node/46557/psn-pdf
November 22, 2017 - Safe handover.
November 22, 2017
Merten H, van Galen LS, Wagner C. Safe handover. BMJ. 2017;359:j4328. doi:10.1136/bmj.j4328.
https://psnet.ahrq.gov/issue/safe-handover
Patient handovers between clinical teams are a common point of information exchange that can be
challenging to perform due to interruptions, produ…
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psnet.ahrq.gov/node/35254/psn-pdf
April 06, 2011 - Adverse events and near miss reporting in the NHS.
April 6, 2011
Shaw R. Adverse events and near miss reporting in the NHS. Quality and Safety in Health Care.
2005;14(4). doi:10.1136/qshc.2004.010553.
https://psnet.ahrq.gov/issue/adverse-events-and-near-miss-reporting-nhs
This study evaluated the utility of a volu…
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psnet.ahrq.gov/node/36488/psn-pdf
January 07, 2011 - Horus meets Nightingale in the modern age: how nursing
communicates with pharmacy in HCIT era.
January 7, 2011
Armstrong I, Cox MA. Horus meets Nightingale in the modern age: How nursing communicates with
pharmacy in HCIT era. Stud Health Technol Inform. 2006;122:585-6.
https://psnet.ahrq.gov/issue/horus-meets-nig…
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psnet.ahrq.gov/node/74167/psn-pdf
December 08, 2021 - National Patient Safety Board Advocacy Coalition.
December 8, 2021
EQT Plaza, 625 Liberty Ave, Ste. 2500, Pittsburgh, PA 15222.
https://psnet.ahrq.gov/issue/national-patient-safety-board-advocacy-coalition
Centralized reporting and analysis of adverse events in health care is a safety improvement model from the
av…
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psnet.ahrq.gov/node/73379/psn-pdf
June 09, 2021 - How medical jargon can make COVID health disparities
even worse.
June 9, 2021
Kritz F. Health Shots. National Public Radio; May 24, 2021.
https://psnet.ahrq.gov/issue/how-medical-jargon-can-make-covid-health-disparities-even-worse
Health literacy efforts address challenges related to both language and effecti…
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psnet.ahrq.gov/node/45503/psn-pdf
October 29, 2017 - All CLEAR? Preparing for IT downtime.
October 29, 2017
Kashiwagi DT, Sexton MD, Graves ES, et al. All CLEAR? Preparing for IT Downtime. Am J Med Qual.
2017;32(5):547-551. doi:10.1177/1062860616667546.
https://psnet.ahrq.gov/issue/all-clear-preparing-it-downtime
Due to the increasing integration of health care proc…
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psnet.ahrq.gov/node/36226/psn-pdf
August 30, 2006 - Framework for a High Performance Health System for the
United States.
August 30, 2006
Mongan JJ. New York, NY; The Commonwealth Fund: 2006.
https://psnet.ahrq.gov/issue/framework-high-performance-health-system-united-states
This report calls for providing "safe, well-coordinated, accessible, and efficient" care th…
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psnet.ahrq.gov/node/39374/psn-pdf
March 17, 2010 - Bridging the gap: leveraging business intelligence tools
in support of patient safety and financial effectiveness.
March 17, 2010
Ferranti JM, Langman MK, Tanaka D, et al. Bridging the gap: leveraging business intelligence tools in
support of patient safety and financial effectiveness. J Am Med Inform Assoc. 2010;1…
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psnet.ahrq.gov/node/34902/psn-pdf
February 27, 2009 - Hospital rules-based system: the next generation of
medical informatics for patient safety.
February 27, 2009
Wilson JW, Oyen LJ, Ou NN, et al. Hospital rules-based system: the next generation of medical informatics
for patient safety. Am J Health Syst Pharm. 2005;62(5):499-505.
https://psnet.ahrq.gov/issue/hospit…
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psnet.ahrq.gov/node/43657/psn-pdf
November 26, 2014 - Strategies for Ensuring the Safe Use of Insulin Pens in the
Hospital.
November 26, 2014
American Society of Health-System Pharmacists
https://psnet.ahrq.gov/issue/strategies-ensuring-safe-use-insulin-pens-hospital
Insulin is classified as a high-alert medication due to the potential to cause serious patient harm w…
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psnet.ahrq.gov/node/39268/psn-pdf
April 01, 2010 - Multi-professional patterns and methods of
communication during patient handoffs.
April 1, 2010
Benham-Hutchins MM, Effken JA. Multi-professional patterns and methods of communication during
patient handoffs. Int J Med Inform. 2010;79(4):252-67. doi:10.1016/j.ijmedinf.2009.12.005.
https://psnet.ahrq.gov/issue/mult…
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psnet.ahrq.gov/node/47166/psn-pdf
July 02, 2019 - Meaningful use's benefits and burdens for US family
physicians.
July 2, 2019
Holman T, Waldren SE, Beasley JW, et al. Meaningful use's benefits and burdens for US family physicians.
J Am Med Inform Assoc. 2018;25(6):694-701. doi:10.1093/jamia/ocx158.
https://psnet.ahrq.gov/issue/meaningful-uses-benefits-and-burden…
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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/44649/psn-pdf
November 11, 2015 - Seven (potentially) deadly prescribing errors.
November 11, 2015
Graham LR, Scudder L, Stokowski L. Medscape. October 22, 2015.
https://psnet.ahrq.gov/issue/seven-potentially-deadly-prescribing-errors
Errors in the prescribing process can lead to adverse drug events. This slide set provides information about
commo…
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psnet.ahrq.gov/node/39861/psn-pdf
September 22, 2010 - A network collaboration implementing technology to
improve medication dispensing and administration in
critical access hospitals.
September 22, 2010
Wakefield DS, Ward MM, Loes JL, et al. A network collaboration implementing technology to improve
medication dispensing and administration in critical access hospital…
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psnet.ahrq.gov/node/44332/psn-pdf
July 29, 2015 - Health IT Safety Center Roadmap.
July 29, 2015
RTI International. Washington, DC: Office of the National Coordinator for Health Information Technology;
July 2015.
https://psnet.ahrq.gov/issue/health-it-safety-center-roadmap
The Institute of Medicine called for enhanced transparency in the reporting of health IT sa…