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psnet.ahrq.gov/issue/oncologist-perceptions-racial-disparity-racial-anxiety-and-unconscious-bias-clinical
October 19, 2022 - Study
Oncologist perceptions of racial disparity, racial anxiety, and unconscious bias in clinical interactions, treatment, and outcomes.
Citation Text:
Balanean A, Bland E, Gajra A, et al. Oncologist perceptions of racial disparity, racial anxiety, and unconscious bias in clinical inter…
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psnet.ahrq.gov/issue/he-thought-lady-door-was-lady-window-qualitative-study-patient-identification-practices
June 14, 2017 - Study
He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices.
Citation Text:
Phipps E, Turkel M, Mackenzie ER, et al. He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identifica…
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digital.ahrq.gov/sites/default/files/docs/page/CarayonSuccessStory.pdf
December 31, 2010 - Toolkit Available for Assessing the Impact of Health InformationTechnology on Workflow in Provider Offices
1
Toolkit Available for Assessing the Impact of Health Information
Technology on Workflow in Provider Offices
Health IT systems
can impact workflow
by changing how,
when, and from
whom a patient
re…
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psnet.ahrq.gov/issue/development-and-validation-electronic-health-record-based-triggers-detect-delays-follow
June 21, 2016 - Study
Development and validation of electronic health record–based triggers to detect delays in follow-up of abnormal lung imaging findings.
Citation Text:
Murphy DR, Thomas EJ, Meyer AND, et al. Development and Validation of Electronic Health Record-based Triggers to Detect Delays in Fo…
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psnet.ahrq.gov/issue/hemodialysis-bleeding-events-and-deaths-18-year-retrospective-analysis-patient-safety-and
June 23, 2021 - Study
Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.
Citation Text:
Walton E, Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: an 18-year retrospectiv…
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psnet.ahrq.gov/issue/patient-misidentification-events-veterans-health-administration-comprehensive-review-context
November 24, 2021 - Study
Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.
Citation Text:
Kulju S, Morrish W, King LA, et al. Patient misidentification events in the Veterans Health Administration: a comprehensive …
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psnet.ahrq.gov/issue/identifying-safety-practices-perceived-low-value-exploratory-survey-healthcare-staff-united
February 03, 2021 - Study
Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia.
Citation Text:
Halligan D, Janes G, Conner M, et al. Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in…
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psnet.ahrq.gov/issue/advanced-medication-reconciliation-systematic-review-impact-medication-errors-and-adverse
December 18, 2017 - Review
Advanced medication reconciliation: a systematic review of the impact on medication errors and adverse drug events associated with transitions of care.
Citation Text:
Killin L, Hezam A, Anderson KK, et al. Advanced medication reconciliation: a systematic review of the impact on me…
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psnet.ahrq.gov/issue/stepped-wedge-cluster-rct-assess-effects-electronic-medication-system-medication
August 28, 2024 - Study
Stepped-wedge cluster RCT to assess the effects of an electronic medication system on medication administration errors.
Citation Text:
Westbrook JI, Li L, Woods AL, et al. Stepped-wedge cluster RCT to assess the effects of an electronic medication system on medication administratio…
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psnet.ahrq.gov/issue/effects-leadership-curricula-and-without-implicit-bias-training-graduate-medical-education
January 31, 2024 - Study
The effects of leadership curricula with and without implicit bias training on graduate medical education: a multicenter randomized trial.
Citation Text:
Hansen M, Harrod T, Bahr N, et al. The effects of leadership curricula with and without implicit bias training on graduate medic…
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psnet.ahrq.gov/issue/adverse-events-related-accidental-unintentional-ingestions-cough-and-cold-medications
May 06, 2020 - Study
Adverse events related to accidental unintentional ingestions from cough and cold medications in children.
Citation Text:
Wang GS, Reynolds KM, Banner W, et al. Adverse events related to accidental unintentional ingestions from cough and cold medications in children. Pediatr Emerg …
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psnet.ahrq.gov/issue/impact-electronic-alert-reduce-risk-co-prescription-low-molecular-weight-heparins-and-direct
August 17, 2022 - Study
The impact of an electronic alert to reduce the risk of co-prescription of low molecular weight heparins and direct oral anticoagulants.
Citation Text:
Brown A, Cavell G, Dogra N, et al. The impact of an electronic alert to reduce the risk of co-prescription of low molecular weight…
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psnet.ahrq.gov/issue/clinical-safety-englands-national-programme-it-retrospective-analysis-all-reported-safety
December 31, 2014 - Study
Classic
Clinical safety of England's national programme for IT: a retrospective analysis of all reported safety events 2005 to 2011.
Citation Text:
Magrabi F, Baker M, Sinha I, et al. Clinical safety of England's national programme for IT: a retrospective …
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psnet.ahrq.gov/issue/implementation-electronic-triggers-identify-diagnostic-errors-emergency-departments
September 25, 2024 - Study
Implementation of electronic triggers to identify diagnostic errors in emergency departments.
Citation Text:
Vaghani V, Gupta A, Mir U, et al. Implementation of electronic triggers to identify diagnostic errors in emergency departments. JAMA Intern Med. 2025;185(2):143-151. doi:10.…
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psnet.ahrq.gov/issue/it-time-mental-health-field-consider-unplanned-discharge-key-metric-patient-safety
June 01, 2022 - Study
Is it time for the mental health field to consider unplanned discharge a key metric of patient safety?
Citation Text:
Riblet NB, Gottlieb DJ, Watts BV, et al. Is it time for the mental health field to consider unplanned discharge a key metric of patient safety? J Nerv Ment Dis. 202…
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www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide8.html
May 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism
Chapter 8. Continue To Improve, Hold the Gains, and Spread the Results
Previous Page Next Page
Table of Contents
Preventing Hospital-Associated Venous Thromboembolism
Preface
Executive Summary
Chapter 1. The Framework for Improvement
Chap…
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digital.ahrq.gov/2019-year-review/research-summary/using-aviation-technology-prevent-healthcare-errors-health-it
January 01, 2019 - Using Aviation Technology to Prevent Healthcare Errors: The Health IT Black Box
Similar to the airline industry’s use of a “black box” that captures actions leading up to a near miss or error, the health IT black box captures mouse movements and keystrokes made by users of EHRs. This allows for a robust analysis of…
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psnet.ahrq.gov/issue/frequency-and-types-patient-reported-errors-electronic-health-record-ambulatory-care-notes
June 05, 2019 - Study
Classic
Frequency and types of patient-reported errors in electronic health record ambulatory care notes.
Citation Text:
Bell SK, Delbanco T, Elmore JG, et al. Frequency and types of patient-reported errors in electronic health record ambulatory care notes…
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psnet.ahrq.gov/issue/understanding-second-victim-experience-among-multidisciplinary-providers-obstetrics-and
December 23, 2020 - Study
Understanding the second victim experience among multidisciplinary providers in obstetrics and gynecology.
Citation Text:
Rivera-Chiauzzi E, Finney RE, Riggan KA, et al. Understanding the second victim experience among multidisciplinary providers in obstetrics and gynecology. J Pat…
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psnet.ahrq.gov/issue/role-bias-clinical-decision-making-people-serious-mental-illness-and-medical-co-morbidities
November 10, 2021 - Review
The role of bias in clinical decision-making of people with serious mental illness and medical co-morbidities: a scoping review.
Citation Text:
Crapanzano KA, Deweese S, Pham D, et al. The role of bias in clinical decision-making of people with serious mental illness and medical c…