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psnet.ahrq.gov/node/837772/psn-pdf
August 03, 2022 - Translating electronic health record-based patient safety
algorithms from research to clinical practice at multiple
sites.
August 3, 2022
Zimolzak AJ, Singh H, Murphy DR, et al. BMJ Health Care Inform. 2022;29(1):e100565.
https://psnet.ahrq.gov/issue/translating-electronic-health-record-based-patient-safety-algori…
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psnet.ahrq.gov/node/866247/psn-pdf
July 10, 2024 - Analysis of critical incident reports using natural
language processing.
July 10, 2024
Denecke K, Paula H. Analysis of critical incident reports using natural language processing. Stud Health
Technol Inform. 2024;313:1-6. doi:10.3233/shti240002.
https://psnet.ahrq.gov/issue/analysis-critical-incident-reports-using…
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psnet.ahrq.gov/node/44222/psn-pdf
December 04, 2016 - The Institute for Safe Medication Practices and poison
control centers: collaborating to prevent medication
errors and unintentional poisonings.
December 4, 2016
Vaida AJ. The Institute for Safe Medication Practices and Poison Control Centers: Collaborating to Prevent
Medication Errors and Unintentional Poisonings…
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psnet.ahrq.gov/node/852802/psn-pdf
August 23, 2023 - Indian Health Service: Actions Needed to Improve Use of
Data on Adverse Events.
August 23, 2023
Washington, DC: United States Government Accounting Office; July 10, 2023. Publication GAO-23-
105722.
https://psnet.ahrq.gov/issue/indian-health-service-actions-needed-improve-use-data-adverse-events
Health info…
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psnet.ahrq.gov/node/40602/psn-pdf
December 31, 2014 - How to improve the delivery of medication alerts within
computerized physician order entry systems: an
international Delphi study.
December 31, 2014
Riedmann D, Jung M, Hackl WO, et al. How to improve the delivery of medication alerts within
computerized physician order entry systems: an international Delphi study…
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psnet.ahrq.gov/node/866951/psn-pdf
October 16, 2024 - Toward a responsible future: recommendations for AI-
enabled clinical decision support.
October 16, 2024
Labkoff S, Oladimeji B, Kannry J, et al. Toward a responsible future: recommendations for AI-enabled
clinical decision support. J Am Med Inform Assoc. 2024;31(11):2730-2739. doi:10.1093/jamia/ocae209.
https://p…
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psnet.ahrq.gov/node/39330/psn-pdf
March 03, 2010 - Consistency between coded poison center data and
fatality abstract narratives for therapeutic error deaths in
older adults.
March 3, 2010
Hayes BD, Klein-Schwartz W. Consistency between coded poison center data and fatality abstract
narratives for therapeutic error deaths in older adults. Clin Toxicol (Phila). 201…
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psnet.ahrq.gov/node/47068/psn-pdf
June 25, 2018 - The need for closed-loop systems for management of
abnormal test results.
June 25, 2018
Zuccotti G, Samal L, Maloney FL, et al. The Need for Closed-Loop Systems for Management of Abnormal
Test Results. Ann Intern Med. 2018;168(11):820-821. doi:10.7326/M17-2425.
https://psnet.ahrq.gov/issue/need-closed-loop-systems…
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psnet.ahrq.gov/node/855106/psn-pdf
November 08, 2023 - Home Health Agencies Failed To Report Over Half of Falls
With Major Injury and Hospitalization Among Their
Medicare Patients.
November 8, 2023
Maxwell A. Washington DC: Office of Inspector General; September 2023. Report no. OEI-05-22-00290.
https://psnet.ahrq.gov/issue/home-health-agencies-failed-report-over-half…
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psnet.ahrq.gov/node/46426/psn-pdf
September 28, 2017 - Toward more proactive approaches to safety in the
electronic health record era.
September 28, 2017
Sittig DF, Singh H. Toward More Proactive Approaches to Safety in the Electronic Health Record Era. Jt
Comm J Qual Patient Saf. 2017;43(10):540-547. doi:10.1016/j.jcjq.2017.06.005.
https://psnet.ahrq.gov/issue/toward…
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psnet.ahrq.gov/node/48124/psn-pdf
July 31, 2019 - Medication safety alert fatigue may be reduced via
interaction design and clinical role tailoring: a systematic
review.
July 31, 2019
Hussain MI, Reynolds TL, Zheng K. Medication safety alert fatigue may be reduced via interaction design
and clinical role tailoring: a systematic review. J Am Med Inform Assoc. 2019…
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psnet.ahrq.gov/node/48059/psn-pdf
June 05, 2019 - Investigating for improvement? Five strategies to ensure
national patient safety investigations improve patient
safety.
June 5, 2019
Macrae C. Investigating for improvement? Five strategies to ensure national patient safety investigations
improve patient safety. J R Soc Med. 2019;112(9):365-369. doi:10.1177/014107…
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psnet.ahrq.gov/node/46707/psn-pdf
October 13, 2018 - Medication errors involving nursing students: a
systematic review.
October 13, 2018
Asensi-Vicente J, Jiménez-Ruiz I, Vizcaya-Moreno F. Medication Errors Involving Nursing Students: A
Systematic Review. Nurse Educ. 2018;43(5):E1-E5. doi:10.1097/NNE.0000000000000481.
https://psnet.ahrq.gov/issue/medication-errors-i…
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psnet.ahrq.gov/node/863217/psn-pdf
February 28, 2024 - Interpreting and coding causal relationships for quality
and safety using ICD-11.
February 28, 2024
Januel J-M, Southern DA, Ghali WA. Interpreting and coding causal relationships for quality and safety
using ICD-11. BMC Med Inform Decis Mak. 2023;21(Suppl 6):385. doi:10.1186/s12911-023-02363-5.
https://psnet.ahrq…
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psnet.ahrq.gov/node/34933/psn-pdf
April 06, 2011 - Insights from the sharp end of intravenous medication
errors: implications for infusion pump technology.
April 6, 2011
Husch M. Insights from the sharp end of intravenous medication errors: implications for infusion pump
technology. Quality and Safety in Health Care. 2005;14(2). doi:10.1136/qshc.2004.011957.
https…
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psnet.ahrq.gov/node/40427/psn-pdf
May 04, 2011 - Development of a tool within the electronic medical
record to facilitate medication reconciliation after hospital
discharge.
May 4, 2011
Schnipper JL, Liang CL, Hamann C, et al. Development of a tool within the electronic medical record to
facilitate medication reconciliation after hospital discharge. J Am Med Inf…
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psnet.ahrq.gov/node/44593/psn-pdf
November 04, 2015 - Integrating computerized clinical decision support
systems into clinical work: a meta-synthesis of qualitative
research.
November 4, 2015
Miller A, Moon B, Anders S, et al. Integrating computerized clinical decision support systems into clinical
work: A meta-synthesis of qualitative research. Int J Med Inform. 201…
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psnet.ahrq.gov/node/60060/psn-pdf
March 18, 2020 - The benefits and burdens of working with patient safety
organizations under the Patient Safety and Quality
Improvement Act of 2005.
March 18, 2020
Dwyer PE, Watts CD. The benefits and burdens of working with patient safety organizations under the
Patient Safety and Quality Improvement Act of 2005. J Health Life Sc…
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psnet.ahrq.gov/node/45455/psn-pdf
June 29, 2017 - JAMA professionalism: disclosure of medical error.
June 29, 2017
Levinson W, Yeung J, Ginsburg S. Disclosure of Medical Error. JAMA. 2016;316(7):764-5.
doi:10.1001/jama.2016.9136.
https://psnet.ahrq.gov/issue/jama-professionalism-disclosure-medical-error
Disclosing medical errors to patients is essential for maint…
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psnet.ahrq.gov/node/45243/psn-pdf
September 14, 2016 - Incidence of speech recognition errors in the emergency
department.
September 14, 2016
Goss FR, Zhou L, Weiner SG. Incidence of speech recognition errors in the emergency department. Int J
Med Inform. 2016;93:70-73. doi:10.1016/j.ijmedinf.2016.05.005.
https://psnet.ahrq.gov/issue/incidence-speech-recognition-error…