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psnet.ahrq.gov/node/40992/psn-pdf
December 15, 2011 - Should patients get direct access to their laboratory test
results?: An answer with many questions.
December 15, 2011
Giardina TD, Singh H. Should patients get direct access to their laboratory test results? An answer with
many questions. JAMA. 2011;306(22):2502-2503. doi:10.1001/jama.2011.1797.
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May 04, 2011 - Does user-centred design affect the efficiency, usability
and safety of CPOE order sets?
May 4, 2011
Chan J, Shojania KG, Easty AC, et al. Does user-centred design affect the efficiency, usability and safety
of CPOE order sets? J Am Med Inform Assoc. 2011;18(3):276-81. doi:10.1136/amiajnl-2010-000026.
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July 28, 2014 - Risk management—learning from the mistakes of others.
July 28, 2014
Meydan C. Risk management--learning from the mistakes of others. J Eval Clin Pract. 2014;20(4):505-7.
doi:10.1111/jep.12165.
https://psnet.ahrq.gov/issue/risk-management-learning-mistakes-others
This commentary introduces a structured process for …
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psnet.ahrq.gov/node/41498/psn-pdf
December 31, 2014 - Standard practices for computerized clinical decision
support in community hospitals: a national survey.
December 31, 2014
Ash JS, McCormack JL, Sittig DF, et al. Standard practices for computerized clinical decision support in
community hospitals: a national survey. J Am Med Inform Assoc. 2012;19(6):980-7. doi:10.…
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May 31, 2017 - Patient handoffs: is cross cover or night shift better?
May 31, 2017
Higgins A, Brannen ML, Heiman HL, et al. Patient Handoffs: Is Cross Cover or Night Shift Better? J Patient
Saf. 2017;13(2):88-92. doi:10.1097/PTS.0000000000000126.
https://psnet.ahrq.gov/issue/patient-handoffs-cross-cover-or-night-shift-better
Du…
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December 31, 2014 - Transmitting and processing electronic prescriptions:
experiences of physician practices and pharmacies.
December 31, 2014
Grossman JM, Cross DA, Boukus ER, et al. Transmitting and processing electronic prescriptions:
experiences of physician practices and pharmacies. J Am Med Inform Assoc. 2012;19(3):353-9.
doi:1…
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November 10, 2015 - Hospital ratings: a guide for the perplexed.
November 10, 2015
Zuger A. Hospital ratings: a guide for the perplexed. JAMA. 2015;313(19):1911-2.
doi:10.1001/jama.2015.5269.
https://psnet.ahrq.gov/issue/hospital-ratings-guide-perplexed
Concerns have been raised about the variability of measures used to rate safety a…
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psnet.ahrq.gov/node/39110/psn-pdf
June 10, 2018 - Order scanning systems may pull multiple pages through
the scanner at the same time, leading to drug omissions.
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3.
https://psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time-
leading-dru…
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psnet.ahrq.gov/node/862619/psn-pdf
February 14, 2024 - FDA urged to move faster to fix pulse oximeters for
darker-skinned patients.
February 14, 2024
McFarling UL. STAT. February 2, 2024.
https://psnet.ahrq.gov/issue/fda-urged-move-faster-fix-pulse-oximeters-darker-skinned-patients
Unequal care has been hardwired into the health system through the persistent implicit …
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psnet.ahrq.gov/node/50875/psn-pdf
February 05, 2020 - Implementing Closing the Loop. Safe Practices for
Diagnostic Results
February 5, 2020
Partnership for HIT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2020.
https://psnet.ahrq.gov/issue/implementing-closing-loop-safe-practices-diagnostic-results
Health information technology (HIT) can improve record keepi…
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psnet.ahrq.gov/node/45058/psn-pdf
February 18, 2017 - Learning from incidents in healthcare: the journey, not
the arrival, matters.
February 18, 2017
Leistikow I, Mulder S, Vesseur J, et al. Learning from incidents in healthcare: the journey, not the arrival,
matters. BMJ Qual Saf. 2017;26(3):252-256. doi:10.1136/bmjqs-2015-004853.
https://psnet.ahrq.gov/issue/learni…
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psnet.ahrq.gov/node/35724/psn-pdf
May 26, 2010 - A prospective study of patient safety in the operating
room.
May 26, 2010
Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room.
Surgery. 2006;139(2):159-173.
https://psnet.ahrq.gov/issue/prospective-study-patient-safety-operating-room
This study used a multidisci…
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December 11, 2024 - Recommendations to ensure safety of AI in real-world
clinical care.
December 11, 2024
Sittig DF, Singh H. Recommendations to ensure safety of AI in real-world clinical care. JAMA.
2025;333(6):457-458. doi:10.1001/jama.2024.24598.
https://psnet.ahrq.gov/issue/recommendations-ensure-safety-ai-real-world-clinical-car…
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psnet.ahrq.gov/node/39378/psn-pdf
March 17, 2010 - Exploring emergency physician–hospitalist handoff
interactions: development of the Handoff Communication
Assessment.
March 17, 2010
Apker J, Mallak LA, Applegate B, et al. Exploring emergency physician-hospitalist handoff interactions:
development of the Handoff Communication Assessment. Ann Emerg Med. 2010;55(2):…
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psnet.ahrq.gov/node/865932/psn-pdf
May 22, 2024 - Cognitive Load Theory and its Impact on Diagnostic
Accuracy.
May 22, 2024
Knees M, Raffel KE, Kissler M, et al. Rockville, MD: Agency for Healthcare Research and Quality; May
2024. Publication No. 24-0010-2-EF.
https://psnet.ahrq.gov/issue/cognitive-load-theory-and-its-impact-diagnostic-accuracy
Cognition plays a…
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psnet.ahrq.gov/node/40603/psn-pdf
December 31, 2014 - ICU nurses' acceptance of electronic health records.
December 31, 2014
Carayon P, Cartmill R, Blosky MA, et al. ICU nurses' acceptance of electronic health records. J Am Med
Inform Assoc. 2011;18(6):812-9. doi:10.1136/amiajnl-2010-000018.
https://psnet.ahrq.gov/issue/icu-nurses-acceptance-electronic-health-records
…
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April 01, 2010 - Human factors engineering in healthcare systems: the
problem of human error and accident management.
April 1, 2010
Cacciabue PC, Vella G. Human factors engineering in healthcare systems: the problem of human error and
accident management. Int J Med Inform. 2010;79(4):e1-17. doi:10.1016/j.ijmedinf.2008.10.005.
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June 29, 2011 - A review of medical error taxonomies: a human factors
perspective.
June 29, 2011
Taib IA, McIntosh AS, Caponecchia C, et al. A review of medical error taxonomies: A human factors
perspective. Saf Sci. 2011;49(5):607-615. doi:10.1016/j.ssci.2010.12.014.
https://psnet.ahrq.gov/issue/review-medical-error-taxonomies-h…
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psnet.ahrq.gov/node/43826/psn-pdf
June 01, 2015 - Radiation Oncology Incident Learning System.
June 1, 2015
American Society for Radiation Oncology and American Association of Physicists in Medicine.
https://psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system
Reporting of near misses and adverse events can provide a foundation for learning from error.…
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psnet.ahrq.gov/node/50809/psn-pdf
January 15, 2020 - Electronic Health Record (EHR) Safety and Usability: See
What We Mean.
January 15, 2020
MedStar Health National Center for Human Factors in Healthcare.
https://psnet.ahrq.gov/issue/electronic-health-record-ehr-safety-and-usability-see-what-we-mean
Electronic health records (EHR) optimize information functions in c…