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psnet.ahrq.gov/node/43573/psn-pdf
October 01, 2014 - Effective communication with primary care providers.
October 1, 2014
Smith K. Effective communication with primary care providers. Pediatr Clin North Am. 2014;61(4):671-679.
doi:10.1016/j.pcl.2014.04.004.
https://psnet.ahrq.gov/issue/effective-communication-primary-care-providers
Highlighting how the disconnect be…
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psnet.ahrq.gov/node/38835/psn-pdf
September 02, 2009 - Impact of a computerized physician order entry system
on compliance with prescription accuracy requirements.
September 2, 2009
Mir C, Gadri A, Zelger GL, et al. Impact of a computerized physician order entry system on compliance with
prescription accuracy requirements. Pharm World Sci. 2009;31(5):596-602. doi:10.10…
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psnet.ahrq.gov/node/34789/psn-pdf
December 23, 2008 - Medication error prevention by pharmacists.
December 23, 2008
Blum K, Abel SR, Urbanski CJ, et al. Medication error prevention by pharmacists. Am J Hosp Pharm.
1988;45(9):1902-3.
https://psnet.ahrq.gov/issue/medication-error-prevention-pharmacists
This study investigated the impact of hospital pharmacists in preve…
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psnet.ahrq.gov/node/40091/psn-pdf
December 15, 2010 - Implementation of a telepharmacy service to provide
round-the-clock medication order review by pharmacists.
December 15, 2010
Wakefield DS, Ward MM, Loes JL, et al. Implementation of a telepharmacy service to provide round-the-
clock medication order review by pharmacists. American Journal of Health-System Pharmacy…
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psnet.ahrq.gov/node/45587/psn-pdf
January 23, 2017 - Comparison of physician and computer diagnostic
accuracy.
January 23, 2017
Semigran HL, Levine DM, Nundy S, et al. Comparison of Physician and Computer Diagnostic Accuracy.
JAMA Intern Med. 2016;176(12):1860-1861. doi:10.1001/jamainternmed.2016.6001.
https://psnet.ahrq.gov/issue/comparison-physician-and-computer-d…
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psnet.ahrq.gov/node/43646/psn-pdf
January 01, 2021 - Patient Safety Systems Chapter.
January 1, 2021
In: 2021 Comprehensive Accreditation Manual for Hospitals. CAMH. Oakbrook Terrace, IL: Joint
Commission; January 2021:PS1-PS46.
https://psnet.ahrq.gov/issue/patient-safety-systems-chapter
This chapter provides information about how organizations can re-design existin…
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psnet.ahrq.gov/node/42981/psn-pdf
March 19, 2014 - Recognizing and managing errors of cognitive
underspecification.
March 19, 2014
Duthie EA. Recognizing and managing errors of cognitive underspecification. J Patient Saf. 2014;10(1):1-5.
doi:10.1097/PTS.0b013e3182a5f6e1.
https://psnet.ahrq.gov/issue/recognizing-and-managing-errors-cognitive-underspecification
Inc…
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psnet.ahrq.gov/node/47025/psn-pdf
April 11, 2018 - Chemotherapy medication errors.
April 11, 2018
Weingart SN, Zhang L, Sweeney M, et al. Chemotherapy medication errors. Lancet Oncol.
2018;19(4):e191-e199. doi:10.1016/S1470-2045(18)30094-9.
https://psnet.ahrq.gov/issue/chemotherapy-medication-errors
Chemotherapy errors can result in serious patient harm. This revi…
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psnet.ahrq.gov/node/41396/psn-pdf
May 23, 2012 - In search of common ground in handoff documentation in
an intensive care unit.
May 23, 2012
Collins S, Mamykina L, Jordan D, et al. In search of common ground in handoff documentation in an
Intensive Care Unit. J Biomed Inform. 2012;45(2):307-15. doi:10.1016/j.jbi.2011.11.007.
https://psnet.ahrq.gov/issue/search-c…
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psnet.ahrq.gov/node/42374/psn-pdf
January 07, 2014 - Patient safety in nursing education: contexts, tensions
and feeling safe to learn.
January 7, 2014
Steven A, Magnusson C, Smith P, et al. Patient safety in nursing education: contexts, tensions and feeling
safe to learn. Nurse Educ Today. 2014;34(2):277-84. doi:10.1016/j.nedt.2013.04.025.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/43741/psn-pdf
December 03, 2014 - Overdiagnosis: how our compulsion for diagnosis may be
harming children.
December 3, 2014
Coon ER, Quinonez RA, Moyer VA, et al. Overdiagnosis: how our compulsion for diagnosis may be
harming children. Pediatrics. 2014;134(5):1013-23. doi:10.1542/peds.2014-1778.
https://psnet.ahrq.gov/issue/overdiagnosis-how-our-c…
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psnet.ahrq.gov/node/35924/psn-pdf
April 14, 2011 - Assessment of the potential impact of a reminder system
on the reduction of diagnostic errors: a quasi-
experimental study.
April 14, 2011
Ramnarayan P, Roberts GC, Coren M, et al. Assessment of the potential impact of a reminder system on
the reduction of diagnostic errors: a quasi-experimental study. BMC Med Inf…
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psnet.ahrq.gov/node/43056/psn-pdf
January 07, 2015 - Electronic handoff instruments: a truly multidisciplinary
tool?
January 7, 2015
Schuster KM, Jenq GY, Thung SF, et al. Electronic handoff instruments: a truly multidisciplinary tool? J Am
Med Inform Assoc. 2014;21(e2):e352-e357. doi:10.1136/amiajnl-2013-002361.
https://psnet.ahrq.gov/issue/electronic-handoff-instr…
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psnet.ahrq.gov/node/37619/psn-pdf
March 19, 2008 - Learning from error: identifying contributory causes of
medication errors in an Australian hospital.
March 19, 2008
Nichols P, Copeland T-S, Craib IA, et al. Learning from error: identifying contributory causes of medication
errors in an Australian hospital. Med J Aust. 2008;188(5):276-9.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/44206/psn-pdf
December 16, 2015 - Your new medical team: algorithms and physicians.
December 16, 2015
Frakt A. New York Times. December 7, 2015.
https://psnet.ahrq.gov/issue/your-new-medical-team-algorithms-and-physicians
Humans are vulnerable to distraction, fatigue, and memory lapses, which can hinder their ability to process
information. This n…
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psnet.ahrq.gov/node/38552/psn-pdf
April 15, 2009 - Understanding pharmacist decision making for adverse
drug event (ADE) detection.
April 15, 2009
Phansalkar S, Hoffman JM, Hurdle JF, et al. Understanding pharmacist decision making for adverse drug
event (ADE) detection. J Eval Clin Pract. 2009;15(2):266-75. doi:10.1111/j.1365-2753.2008.00992.x.
https://psnet.ahrq…
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psnet.ahrq.gov/node/42929/psn-pdf
February 05, 2014 - Do no harm: is it time to rethink the Hippocratic Oath?
February 5, 2014
Walton M, Kerridge I. Do no harm: is it time to rethink the Hippocratic Oath? Med Educ. 2014;48(1):17-27.
doi:10.1111/medu.12275.
https://psnet.ahrq.gov/issue/do-no-harm-it-time-rethink-hippocratic-oath
This commentary discusses how health ca…
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psnet.ahrq.gov/node/46095/psn-pdf
April 26, 2017 - Impact of Medical Errors and Malpractice on Health
Economics, Quality, and Patient Safety.
April 26, 2017
Riga M, ed. Hershey, PA: IGI Global; 2017. ISBN: 9781522523376.
https://psnet.ahrq.gov/issue/impact-medical-errors-and-malpractice-health-economics-quality-and-patient-
safety
This book provides information o…
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psnet.ahrq.gov/node/36736/psn-pdf
March 21, 2012 - FDA preliminary public health notification: unpredictable
events in medical equipment due to new daylight savings
time change.
March 21, 2012
Silver Spring MD; Center for Devices and Radiological Health, Food and Drug Administration; March1,
2007.
https://psnet.ahrq.gov/issue/fda-preliminary-public-health-notific…
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psnet.ahrq.gov/node/44437/psn-pdf
September 04, 2015 - A piece of my mind. Writing the wrong.
September 4, 2015
Patel JJ. A PIECE OF MY MIND. Writing the Wrong. JAMA. 2015;314(7):671-2.
doi:10.1001/jama.2015.5281.
https://psnet.ahrq.gov/issue/piece-my-mind-writing-wrong
Despite the potential for electronic health record (EHR) systems to improve access to patient data,…