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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - SPOTLIGHT CASE
The Hazards of Distraction: Ticking All the EHR Boxes
Citation Text:
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care
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December 23, 2020
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/sites/default/files/2020-07/spotlight_nstemi.pdf
January 01, 2020 - Spotlight
The NSTEMI Curbside
Consultation
Source and Credits
• This presentation is based on the July 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Amparo C. Villablanca, MD and Gordon Wong, MD
MBA
o AHRQ WebM&M Editors …
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psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation?
Ashish K. Jha, MD, MPH | September 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Jha AK. What Can the Rest of the Heal…
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psnet.ahrq.gov/node/46587/psn-pdf
January 23, 2019 - Association between workarounds and medication
administration errors in bar-code-assisted medication
administration in hospitals.
January 23, 2019
van der Veen W, van den Bemt PMLA, Wouters H, et al. Association between workarounds and medication
administration errors in bar-code-assisted medication administration…
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psnet.ahrq.gov/node/44266/psn-pdf
May 19, 2019 - Exploring health care professionals' perceptions of
incidents and incident reporting in rehabilitation settings.
May 19, 2019
Espin S, Carter C, Janes N, et al. Exploring Health Care Professionals' Perceptions of Incidents and
Incident Reporting in Rehabilitation Settings. J Patient Saf. 2019;15(2):154-160.
doi:10…
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psnet.ahrq.gov/node/47136/psn-pdf
July 02, 2019 - Adherence to recommended electronic health record
safety practices across eight health care organizations.
July 2, 2019
Sittig DF, Salimi M, Aiyagari R, et al. Adherence to recommended electronic health record safety practices
across eight health care organizations. J Am Med Inform Assoc. 2018;25(7):913-918.
doi:1…
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psnet.ahrq.gov/node/38076/psn-pdf
February 15, 2011 - Consequences of inadequate sign-out for patient care.
February 15, 2011
Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequate sign-out for patient care. Arch Intern
Med. 2008;168(16):1755-60. doi:10.1001/archinte.168.16.1755.
https://psnet.ahrq.gov/issue/consequences-inadequate-sign-out-patient-care
W…
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psnet.ahrq.gov/node/42653/psn-pdf
January 07, 2015 - Exploring the sociotechnical intersection of patient safety
and electronic health record implementation.
January 7, 2015
Meeks DW, Takian A, Sittig DF, et al. Exploring the sociotechnical intersection of patient safety and
electronic health record implementation. J Am Med Inform Assoc. 2014;21(e1):e28-e34.
doi:10.…
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psnet.ahrq.gov/node/45395/psn-pdf
August 10, 2016 - Adverse inpatient outcomes during the transition to a new
electronic health record system: observational study.
August 10, 2016
Barnett ML, Mehrotra A, Jena AB. Adverse inpatient outcomes during the transition to a new electronic
health record system: observational study. BMJ. 2016;354:i3835. doi:10.1136/bmj.i3835.…
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psnet.ahrq.gov/node/46203/psn-pdf
June 14, 2017 - Prescription errors related to the use of computerized
provider order-entry system for pediatric patients.
June 14, 2017
Alhanout K, Bun S-S, Retornaz K, et al. Prescription errors related to the use of computerized provider
order-entry system for pediatric patients. Int J Med Inform. 2017;103:15-19.
doi:10.1016/j…
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psnet.ahrq.gov/node/38411/psn-pdf
December 16, 2014 - A reengineered hospital discharge program to decrease
rehospitalization: a randomized trial.
December 16, 2014
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease
rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-87.
https://psnet.ahrq.gov/issue/reengine…
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psnet.ahrq.gov/node/41789/psn-pdf
September 01, 2016 - Drug–drug interactions that should be non-interruptive in
order to reduce alert fatigue in electronic health records.
September 1, 2016
Phansalkar S, van der Sijs H, Tucker AD, et al. Drug-drug interactions that should be non-interruptive in
order to reduce alert fatigue in electronic health records. J Am Med Infor…
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psnet.ahrq.gov/node/42342/psn-pdf
December 31, 2014 - The safety of electronic prescribing: manifestations,
mechanisms, and rates of system-related errors
associated with two commercial systems in hospitals.
December 31, 2014
Westbrook JI, Baysari M, Li L, et al. The safety of electronic prescribing: manifestations, mechanisms, and
rates of system-related errors asso…
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psnet.ahrq.gov/issue/self-reported-medical-medication-and-laboratory-error-eight-countries-risk-factors
September 19, 2012 - Study
Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults.
Citation Text:
Scobie A. Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults. Int J Qual Health Care. 2…
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psnet.ahrq.gov/issue/randomized-controlled-trial-evaluating-impact-computerized-rounding-and-sign-out-system
July 14, 2010 - Study
Classic
A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours.
Citation Text:
Van Eaton EG, Horvath KD, Lober WB, et al. A randomized, controlled trial evaluating…
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psnet.ahrq.gov/issue/use-novel-electronic-health-record-centered-interprofessional-icu-rounding-simulation
March 04, 2019 - Study
Use of a novel, electronic health record–centered, interprofessional ICU rounding simulation to understand latent safety issues.
Citation Text:
Bordley J, Sakata KK, Bierman J, et al. Use of a Novel, Electronic Health Record-Centered, Interprofessional ICU Rounding Simulation to Un…
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psnet.ahrq.gov/issue/intended-and-unintended-consequences-communication-systems-general-internal-medicine
October 31, 2011 - Study
The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals.
Citation Text:
Wu RC, Lo V, Morra D, et al. The intended and unintended consequences of communi…
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psnet.ahrq.gov/issue/optimizing-patient-safety-clinical-trials-improving-transitions-care
October 16, 2024 - Study
Optimizing patient safety in clinical trials by improving transitions of care.
Citation Text:
Nair SC, Satish KP, Al Maini M, et al. Optimizing patient safety in clinical trials by improving transitions of care. Jt Comm J Qual Patient Saf. 2020;46(4). doi:10.1016/j.jcjq.2020.01.001…