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psnet.ahrq.gov/issue/workarounds-workplace-second-look
December 08, 2021 - Commentary
Workarounds in the workplace: a second look.
Citation Text:
Seaman JB, Erlen JA. Workarounds in the Workplace: A Second Look. Orthop Nurs. 2015;34(4):235-242. doi:10.1097/NOR.0000000000000161.
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psnet.ahrq.gov/issue/safety-through-redundancy-case-study-hospital-patient-transfers
November 03, 2015 - Study
Safety through redundancy: a case study of in-hospital patient transfers.
Citation Text:
Ong M-S, Coiera E. Safety through redundancy: a case study of in-hospital patient transfers. Qual Saf Health Care. 2010;19(5):e32. doi:10.1136/qshc.2009.035972.
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psnet.ahrq.gov/issue/reasons-provided-prescribers-when-overriding-drug-drug-interaction-alerts
April 27, 2010 - Study
Reasons provided by prescribers when overriding drug–drug interaction alerts.
Citation Text:
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.
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psnet.ahrq.gov/issue/essential-activities-electronic-health-record-safety-qualitative-study
April 29, 2018 - Study
Essential activities for electronic health record safety: a qualitative study.
Citation Text:
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. …
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psnet.ahrq.gov/node/49604/psn-pdf
June 01, 2010 - Tacit Handover, Overt Mishap
June 1, 2010
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
The Case
A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3
years earlier to treat an abdo…
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psnet.ahrq.gov/print/pdf/node/74277
January 01, 2021 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Medication/Drug Errors
Curated Library
Primers
Medication Administration Errors
Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March,
12 2021
Medication administration errors are a persistent patient saf…
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psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
August 01, 2019 - Medical Scribes and Patient Safety
Deborah Woodcock, MS, MBA; Robby Bergstrom | August 1, 2019
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Woodcock D, Bergstrom R. Medical Scribes and Patient Safety. PSNet [internet]. Rockv…
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psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
August 01, 2015 - In Conversation With… Robert M. Wachter, MD
August 1, 2015
Also Read an Essay
Citation Text:
In Conversation With… Robert M. Wachter, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…
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psnet.ahrq.gov/perspective/conversation-susan-smith-md
August 01, 2019 - In Conversation With… Susan Smith, MD
August 1, 2019
Also Read an Essay
Citation Text:
In Conversation With… Susan Smith, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD
August 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and How to Fix It
Jerry Gurwitz, MD | August 1, 2012
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix I…
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psnet.ahrq.gov/node/49807/psn-pdf
October 01, 2017 - Translating From Normal to Abnormal
October 1, 2017
Turner AM. Translating From Normal to Abnormal. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/translating-normal-abnormal
Case Objectives
Define limited English proficiency.
Understand the principal approaches to machine translation.
Review the way mach…
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - U.S. Department of Veterans Affairs Medical Center,
Houston, TX, and Baylor College of Medicine Revised
Safer Diagnosis (Safer Dx) Instrument
January 26, 2022
https://psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-
college-medicine
Summary
The Revised Safer Dx Instr…
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - SPOTLIGHT CASE
The Case of Mistaken Intubation
Citation Text:
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - SPOTLIGHT CASE
Signout Fallout
Citation Text:
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/33609/psn-pdf
March 15, 2025 - Clinical Decision Support Systems
March 15, 2025
Clinical Decision Support Systems. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/clinical-decision-support-systems
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice…
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psnet.ahrq.gov/node/43895/psn-pdf
November 03, 2015 - The Digital Doctor: Hope, Hype, and Harm at the Dawn of
Medicine's Computer Age.
November 3, 2015
Wachter R. New York, NY: McGraw-Hill; 2015. ISBN: 9780071849463.
https://psnet.ahrq.gov/issue/digital-doctor-hope-hype-and-harm-dawn-medicines-computer-age
Over the past few years, driven by $30 billion of federal inc…
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psnet.ahrq.gov/node/39422/psn-pdf
March 23, 2011 - Organisational readiness: exploring the preconditions for
success in organisation-wide patient safety improvement
programmes.
March 23, 2011
Burnett S, Benn J, Pinto A, et al. Organisational readiness: exploring the preconditions for success in
organisation-wide patient safety improvement programmes. Qual Saf Heal…
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psnet.ahrq.gov/node/867638/psn-pdf
February 26, 2025 - Artificial intelligence related safety issues associated with
FDA medical device reports.
February 26, 2025
Handley JL, Krevat SA, Fong A, et al. Artificial intelligence related safety issues associated with FDA
medical device reports. NPJ Digit Med. 2024;7(1):351. doi:10.1038/s41746-024-01357-5.
https://psnet.ahr…
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psnet.ahrq.gov/node/42588/psn-pdf
September 18, 2013 - Cognitive debiasing; part 1 and part 2.
September 18, 2013
Croskerry P, Singhal G, Mamede S. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ
Qual Saf. 2013;22 Suppl 2:ii58-ii64. doi:10.1136/bmjqs-2012-001712.
https://psnet.ahrq.gov/issue/cognitive-debiasing-part-1-and-part-2
Experienced diagnos…