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psnet.ahrq.gov/node/42850/psn-pdf
May 21, 2019 - Confronting safety gaps across labor and delivery teams.
May 21, 2019
Maxfield DG, Lyndon A, Kennedy HP, et al. Confronting safety gaps across labor and delivery teams. Am J
Obstet Gynecol. 2013;209(5). doi:10.1016/j.ajog.2013.07.013.
https://psnet.ahrq.gov/issue/confronting-safety-gaps-across-labor-and-delivery-te…
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psnet.ahrq.gov/node/39576/psn-pdf
September 25, 2010 - Taking Care of Myself: A Guide for When I Leave the
Hospital.
September 25, 2010
Rockville, MD: Agency for Healthcare Research and Quality; April 2010. AHRQ Publication No. 10-0059.
https://psnet.ahrq.gov/issue/taking-care-myself-guide-when-i-leave-hospital
This guide provides patients with information they need t…
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psnet.ahrq.gov/node/60685/psn-pdf
July 15, 2020 - Latent bias and the implementation of artificial
intelligence in medicine.
July 15, 2020
Decamp M, Lindvall C. Latent bias and the implementation of artificial intelligence in medicine. J Am Med
Inform Assoc. 2020;27(12):2020-2023. doi:10.1093/jamia/ocaa094.
https://psnet.ahrq.gov/issue/latent-bias-and-implementat…
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psnet.ahrq.gov/node/34783/psn-pdf
March 28, 2005 - The organizational and intraorganizational development
of disasters.
March 28, 2005
Turner BA. The Organizational and Interorganizational Development of Disasters. Adm Sci Q.
1976;21(3):378. doi:10.2307/2391850.
https://psnet.ahrq.gov/issue/organizational-and-intraorganizational-development-disasters
This article…
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psnet.ahrq.gov/node/44875/psn-pdf
March 02, 2016 - "Teach-back" from a patient's perspective.
March 2, 2016
Miller S, Lattanzio M, Cohen S. "Teach-back" from a patient's perspective. Nursing (Brux). 2016;46(2):63-4.
doi:10.1097/01.NURSE.0000476249.18503.f5.
https://psnet.ahrq.gov/issue/teach-back-patients-perspective
The teach-back method, having patients repeat i…
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psnet.ahrq.gov/node/41038/psn-pdf
February 10, 2012 - Activating knowledge for patient safety practices: a
Canadian academic-policy partnership.
February 10, 2012
Harrison MB, Nicklin W, Owen M, et al. Activating knowledge for patient safety practices: a Canadian
academic-policy partnership. Worldviews Evid Based Nurs. 2012;9(1):49-58. doi:10.1111/j.1741-
6787.2011.0…
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psnet.ahrq.gov/node/41386/psn-pdf
May 16, 2012 - Investigating the Prevalence and Causes of Prescribing
Errors in General Practice: The PRACtICe Study.
May 16, 2012
Avery T, Barber N, Ghaleb M, et al. London, UK: General Medical Council; May 2, 2012.
https://psnet.ahrq.gov/issue/investigating-prevalence-and-causes-prescribing-errors-general-practice-
practice-st…
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psnet.ahrq.gov/node/46368/psn-pdf
October 31, 2017 - A piece of my mind. Trials and tribulations.
October 31, 2017
Brown JL. Trials and Tribulations. JAMA. 2017;318(7). doi:10.1001/jama.2017.7106.
https://psnet.ahrq.gov/issue/piece-my-mind-trials-and-tribulations
Personal experiences can inform understanding of medical error. This commentary describes a physician's
…
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psnet.ahrq.gov/node/40677/psn-pdf
August 10, 2011 - Board quality scorecards: measuring improvement.
August 10, 2011
Goeschel CA, Berenholtz SM, Culbertson R, et al. Board quality scorecards: measuring improvement. Am
J Med Qual. 2011;26(4):254-60. doi:10.1177/1062860610389324.
https://psnet.ahrq.gov/issue/board-quality-scorecards-measuring-improvement
Hospital boa…
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psnet.ahrq.gov/node/45241/psn-pdf
October 31, 2023 - Hospital Harm Project.
October 31, 2023
Canadian Institute for Health Information, Health Excellence Canada.
https://psnet.ahrq.gov/issue/hospital-harm-project
Reducing preventable harm associated with health care is a worldwide goal. This Canadian initiative
developed a measure to track unintended harm in acute c…
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psnet.ahrq.gov/node/41321/psn-pdf
April 25, 2012 - Cognitive balanced model: a conceptual scheme of
diagnostic decision making.
April 25, 2012
Lucchiari C, Pravettoni G. Cognitive balanced model: a conceptual scheme of diagnostic decision making.
J Eval Clin Pract. 2012;18(1):82-8. doi:10.1111/j.1365-2753.2011.01771.x.
https://psnet.ahrq.gov/issue/cognitive-balanc…
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psnet.ahrq.gov/node/37780/psn-pdf
March 10, 2011 - Evaluation of an inpatient computerized medication
reconciliation system.
March 10, 2011
Turchin A, Hamann C, Schnipper JL, et al. Evaluation of an inpatient computerized medication
reconciliation system. J Am Med Inform Assoc. 2008;15(4):449-52. doi:10.1197/jamia.M2561.
https://psnet.ahrq.gov/issue/evaluation-inp…
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psnet.ahrq.gov/node/42563/psn-pdf
October 09, 2013 - Quick Response codes for surgical safety: a prospective
pilot study.
October 9, 2013
Dixon JL, Smythe WR, Momsen LS, et al. Quick Response codes for surgical safety: a prospective pilot
study. Journal of Surgical Research. 2013;184(1). doi:10.1016/j.jss.2013.06.036.
https://psnet.ahrq.gov/issue/quick-response-code…
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psnet.ahrq.gov/node/36288/psn-pdf
December 23, 2016 - Preventing adverse events caused by emergency
electrical power system failures.
December 23, 2016
Preventing adverse events caused by emergency electrical power system failures. Sentinel Event Alert.
2006;37(37):1-3.
https://psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system-
…
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psnet.ahrq.gov/node/40998/psn-pdf
December 14, 2011 - Identifying unintended consequences of quality
indicators: a qualitative study.
December 14, 2011
Lester HE, Hannon KL, Campbell S. Identifying unintended consequences of quality indicators: a
qualitative study. BMJ Qual Saf. 2011;20(12):1057-61. doi:10.1136/bmjqs.2010.048371.
https://psnet.ahrq.gov/issue/identify…
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psnet.ahrq.gov/node/60691/psn-pdf
July 15, 2020 - A mixed-methods systematic review of interventions to
address incivility in nursing.
July 15, 2020
Olsen JM, Aschenbrenner A, Merkel R, et al. A mixed-methods systematic review of interventions to
address incivility in nursing. J Nurs Educ. 2020;59(6):319-326. doi:10.3928/01484834-20200520-04.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/35091/psn-pdf
November 04, 2015 - Development of an expert system for classification of
medical errors.
November 4, 2015
Kopec D, Levy K, Kabir M, et al. Development of an expert system for classification of medical errors. Stud
Health Technol Inform. 2005;114:110-6.
https://psnet.ahrq.gov/issue/development-expert-system-classification-medical-err…
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psnet.ahrq.gov/node/34971/psn-pdf
May 11, 2005 - Scanning out medication errors: Ohio Valley Hospital's
automated IV system provides real-time access to patient
data.
May 11, 2005
Carbasho T.
https://psnet.ahrq.gov/issue/scanning-out-medication-errors-ohio-valley-hospitals-automated-iv-system-
provides-real-time
This article reports on Ohio Valley General Hosp…
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psnet.ahrq.gov/node/36560/psn-pdf
May 27, 2011 - Focus on Computerized Provider Order Entry.
May 27, 2011
J Am Med Inform Assoc. 2007 Jan-Feb;14(1):25-75
https://psnet.ahrq.gov/issue/focus-computerized-provider-order-entry
This special section on computerized provider order entry (CPOE) contains six articles on topics such as
evaluating CPOE systems and interfac…
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psnet.ahrq.gov/node/40999/psn-pdf
January 01, 2012 - Improving patient safety via automated laboratory-based
adverse event grading.
December 15, 2011
Niland JC, Stiller T, Neat J, et al. Improving patient safety via automated laboratory-based adverse event
grading. J Am Med Inform Assoc. 2012;19(1):111-5. doi:10.1136/amiajnl-2011-000513.
https://psnet.ahrq.gov/issue…