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psnet.ahrq.gov/issue/impact-declining-clinical-autopsy-need-revised-healthcare-policy
February 14, 2018 - Review
The impact of declining clinical autopsy: need for revised healthcare policy.
Citation Text:
Xiao J, Krueger GRF, Buja M, et al. The impact of declining clinical autopsy: need for revised healthcare policy. Am J Med Sci. 2009;337(1):41-6. doi:10.1097/MAJ.0b013e318184ce2b.
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psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study
July 20, 2022 - Study
Effect of a hospital command centre on patient safety: an interrupted time series study.
Citation Text:
Effect of a hospital command centre on patient safety: an interrupted time series study. Mebrahtu TF, McInerney CD, Benn J, et al. BMJ Health Care Inform. 2023;30(1):e100653…
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psnet.ahrq.gov/issue/barriers-self-reporting-patient-safety-incidents-paramedics-mixed-methods-study
November 16, 2022 - Study
Barriers to self-reporting patient safety incidents by paramedics: a mixed methods study.
Citation Text:
Sinclair JE, Austin MA, Bourque C, et al. Barriers to Self-Reporting Patient Safety Incidents by Paramedics: A Mixed Methods Study. Prehosp Emerg Care. 2018;22(6):762-772. doi:1…
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psnet.ahrq.gov/issue/complexity-bias-prevention-iatrogenic-injury-why-specific-harms-may-inhibit-performance
September 23, 2020 - Commentary
Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance.
Citation Text:
Padula WV, Armstrong DG, Goldman DP. Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. Mayo Clin Proc. 2022;97(2…
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psnet.ahrq.gov/issue/problem-checklists
March 29, 2023 - Commentary
The problem with checklists.
Citation Text:
Catchpole K, Russ S. The problem with checklists. BMJ Qual Saf. 2015;24(9):545-9. doi:10.1136/bmjqs-2015-004431.
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psnet.ahrq.gov/issue/measurement-and-monitoring-safety-framework-mmsf-learning-its-implementation-canada
September 24, 2018 - Commentary
Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada.
Citation Text:
Carthey J. Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada. BMJ Qual Saf. 2023;32(8):441-443. doi:10.1136/bmjqs-2…
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psnet.ahrq.gov/issue/prevention-fall-related-injuries-long-term-care-randomized-controlled-trial-staff-education
February 17, 2011 - Study
Prevention of fall-related injuries in long-term care: a randomized controlled trial of staff education.
Citation Text:
Ray WA, Taylor JA, Brown AK, et al. Prevention of fall-related injuries in long-term care: a randomized controlled trial of staff education. Arch Intern Med. 20…
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psnet.ahrq.gov/issue/perioperative-patient-safety-correct-patient-correct-surgery-correct-side-multifaceted-cross
December 21, 2011 - Study
Perioperative patient safety: correct patient, correct surgery, correct side--a multifaceted, cross-organizational, interventional study.
Citation Text:
Zohar E, Noga Y, Davidson E, et al. Perioperative patient safety: correct patient, correct surgery, correct side--a multifacete…
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psnet.ahrq.gov/issue/best-practices-developing-proprietary-names-human-nonprescription-drug-products
December 23, 2020 - Press Release/Announcement
Best Practices in Developing Proprietary Names for Human Nonprescription Drug Products.
Citation Text:
Best Practices in Developing Proprietary Names for Human Nonprescription Drug Products. Rockville, MD: US Department of Health and Human Services, Food and Dr…
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psnet.ahrq.gov/issue/undertriage-elderly-trauma-patients-state-designated-trauma-centers
December 08, 2021 - Study
Undertriage of elderly trauma patients to state-designated trauma centers.
Citation Text:
Chang DC, Bass RR, Cornwell EE, et al. Undertriage of elderly trauma patients to state-designated trauma centers. Arch Surg. 2008;143(8):776-782. doi:10.1001/archsurg.143.8.776.
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psnet.ahrq.gov/issue/opioids-medicare-part-d-concerns-about-extreme-use-and-questionable-prescribing
October 29, 2008 - Book/Report
Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing.
Citation Text:
Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing. Office of the Inspector General. Washington, DC: US Department of Health and Human Services…
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psnet.ahrq.gov/issue/high-reliability-leadership-conceptual-framework
March 09, 2022 - Commentary
High reliability leadership: a conceptual framework.
Citation Text:
Martínez-Córcoles M. High reliability leadership: A conceptual framework. J Contingencies Crisis Manage. 2017;26(2):237-246. doi:10.1111/1468-5973.12187.
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psnet.ahrq.gov/issue/intravenous-medication-safety-and-smart-infusion-systems-lessons-learned-and-future
January 09, 2008 - Commentary
Intravenous medication safety and smart infusion systems: lessons learned and future opportunities.
Citation Text:
Keohane C, Hayes J, Saniuk C, et al. Intravenous medication safety and smart infusion systems: lessons learned and future opportunities. J Infus Nurs. 2005;28(5…
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psnet.ahrq.gov/issue/cpoe-it-dont-come-easy
May 27, 2009 - Newspaper/Magazine Article
CPOE: it don't come easy.
Citation Text:
Anderson HJ. CPOE: it don't come easy. Health Data Manag. 2009;17(1):18-20, 22, 24 passim.
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - phenomenon occurs because of the sheer number of alerts, and it is compounded by the fact that the vast majority … Clinicians generally override the vast majority of CPOE warnings, even "critical" alerts that warn
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psnet.ahrq.gov/issue/why-simulation-matters-systematic-review-medical-errors-occurring-during-simulated-health
September 25, 2019 - Citation
Related Resources From the Same Author(s)
Debunking the myth that the majority
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psnet.ahrq.gov/curated-library/diagnostic-error
September 01, 2025 - The majority of the diagnostic errors resulted in some form of clinical impact, including short-term … Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases … Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - ineffective strategy for preventing further patient safety mishaps, particularly
considering that the majority … The majority of respondents, in all groups,
endorsed punitive measures such as fines, suspensions, or
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - High-Risk Pregnancy Program links clinicians and
patients across the state with UAMS, where the vast majority … Pregnancy Program links patients and clinicians across the state with the medical center,
where the vast majority … The majority of
referrals continue to be managed locally, but patients with abnormal findings may be … access to consultations: Since the implementation of the High-Risk Pregnancy
Program in 2003, the vast majority … Renewing annually, the program contract dedicates
the majority of funding toward the telemedicine infrastructure
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psnet.ahrq.gov/node/33853/psn-pdf
March 01, 2018 - But it is
disappointing that in the majority of hospitals there has been no change, and some hospitals … A majority of nurses say that they and other staff feel like their mistakes are held against them
and … RW: The majority of nurses in hospitals are working with and through technology.