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psnet.ahrq.gov/issue/do-no-harm-and-most-good-ai-health-care
March 19, 2019 - Commentary
To do no harm - and the most good - with AI in health care.
Citation Text:
Goldberg CB, Adams L, Blumenthal D, et al. To do no harm - and the most good - with AI in health care. NEJM AI. 2024;1(3). doi:10.1056/aip2400036.
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psnet.ahrq.gov/issue/creating-integrated-patient-safety-team
January 04, 2017 - Commentary
Classic
Creating an integrated patient safety team.
Citation Text:
Gandhi TK, Graydon-Baker E, Barnes JN, et al. Creating an integrated patient safety team. Jt Comm J Qual Saf. 2003;29(8):383-90.
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psnet.ahrq.gov/issue/effect-comprehensive-obstetric-patient-safety-program-compensation-payments-and-sentinel
July 26, 2010 - Study
Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events.
Citation Text:
Grunebaum A, Chervenak F, Skupski D. Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. Am J Obstet Gyneco…
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psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis
January 10, 2018 - Book/Report
Medical Device Use Error: Root Cause Analysis.
Citation Text:
Medical Device Use Error: Root Cause Analysis. Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790.
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psnet.ahrq.gov/issue/rethinking-patient-safety-discussion-guide-patients-healthcare-providers-and-leaders
August 24, 2022 - Toolkit
Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders.
Citation Text:
Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders. Gilbert R, Asselbergs M, Davis D, et al. Healthcare Excellence Canada; 2023.
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psnet.ahrq.gov/issue/ambiguity-and-workarounds-contributors-medical-error
December 23, 2008 - Commentary
Ambiguity and workarounds as contributors to medical error.
Citation Text:
Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med. 2005;142(8):627-630.
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psnet.ahrq.gov/issue/voluntary-incident-reporting-anaesthetic-trainees-australian-hospital
August 17, 2005 - Study
Voluntary incident reporting by anaesthetic trainees in an Australian hospital.
Citation Text:
Freestone L, Bolsin S, Colson M, et al. Voluntary incident reporting by anaesthetic trainees in an Australian hospital. Int J Qual Health Care. 2006;18(6):452-7.
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psnet.ahrq.gov/issue/problem-incident-reporting
February 28, 2024 - Commentary
The problem with incident reporting.
Citation Text:
Macrae C. The problem with incident reporting. BMJ Qual Saf. 2016;25(2):71-75. doi:10.1136/bmjqs-2015-004732.
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psnet.ahrq.gov/issue/health-information-technology-related-wrong-patient-errors-context-critical
June 01, 2022 - Study
Health information technology-related wrong-patient errors: context is critical.
Citation Text:
Health information technology-related wrong-patient errors: context is critical. Kim T, Howe J, Franklin E, et al. Patient Safety. 2020;2(4):40–57.
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psnet.ahrq.gov/issue/laneys-story-problem-delayed-diagnosis-pediatric-stroke
April 24, 2018 - Commentary
Laney's story: the problem of delayed diagnosis of pediatric stroke.
Citation Text:
Fitzsimons BT, Fitzsimons LL, Sun LR. Laney's Story: The Problem of Delayed Diagnosis of Pediatric Stroke. Pediatrics. 2019;143(4):e20183458. doi:10.1542/peds.2018-3458.
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psnet.ahrq.gov/issue/building-cultures-high-reliability-lessons-high-reliability-organization-paradigm
September 05, 2018 - Review
Building cultures of high reliability: lessons from the high reliability organization paradigm.
Citation Text:
Sutcliffe KM. Building cultures of high reliability: lessons from the high reliability organization paradigm. Anesthesiol Clin. 2023;41(4):707-717. doi:10.1016/j.anclin.2…
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psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery
May 30, 2012 - Multi-use Website
Classic
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
Citation Text:
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. The Joint Commission.
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psnet.ahrq.gov/issue/state-science-human-factors-and-ergonomics-healthcare
April 01, 2015 - Commentary
State of science: human factors and ergonomics in healthcare.
Citation Text:
Hignett S, Carayon P, Buckle P, et al. State of science: human factors and ergonomics in healthcare. Ergonomics. 2013;56(10):1491-503. doi:10.1080/00140139.2013.822932.
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psnet.ahrq.gov/issue/medical-error-and-human-factors-engineering-where-are-we-now
August 04, 2021 - Review
Medical error and human factors engineering: where are we now?
Citation Text:
Gawron VJ, Drury CG, Fairbanks RJ, et al. Medical error and human factors engineering: where are we now? Am J Med Qual. 2006;21(1):57-67.
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www.ahrq.gov/cahps/surveys-guidance/item-sets/literacy/index.html
December 01, 2022 - CAHPS Health Literacy Item Sets
The CAHPS Health Literacy Item Sets ask about providers' efforts to foster and improve the health literacy of patients. Health literacy is commonly defined as patients' ability to obtain, process, and understand the basic health information and services they need to make appropri…
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psnet.ahrq.gov/issue/kaiser-permanentes-performance-improvement-system-part-4-creating-learning-organization
July 19, 2023 - Commentary
Kaiser Permanente's performance improvement system, part 4: creating a learning organization.
Citation Text:
Schilling L, Dearing JW, Staley P, et al. Kaiser Permanente's performance improvement system, Part 4: Creating a learning organization. Jt Comm J Qual Patient Saf. 2011…
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psnet.ahrq.gov/issue/natural-language-processing-approach-categorise-contributing-factors-patient-safety-event
April 26, 2023 - Study
A natural language processing approach to categorise contributing factors from patient safety event reports.
Citation Text:
A natural language processing approach to categorise contributing factors from patient safety event reports. Tabaie A, Sengupta S, Pruitt ZM, et al. BMJ Healt…
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psnet.ahrq.gov/issue/intravenous-infusion-safety-technology-return-investment
October 29, 2017 - Study
Intravenous infusion safety technology: return on investment.
Citation Text:
Danello SH, Maddox RR, Schaack GJ. Intravenous Infusion Safety Technology: Return on Investment. Hosp Pharm. 2010;44(8):680-688. doi:10.1310/hpj4408-680.
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psnet.ahrq.gov/issue/inpatient-suicide-preventing-common-sentinel-event
May 28, 2015 - Review
Inpatient suicide: preventing a common sentinel event.
Citation Text:
Tishler CL, Reiss NS. Inpatient suicide: preventing a common sentinel event. Gen Hosp Psychiatry. 2009;31(2):103-9. doi:10.1016/j.genhosppsych.2008.09.007.
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psnet.ahrq.gov/issue/hospital-ran-out-her-childs-cancer-drug-now-shes-fighting-end-shortages
February 06, 2019 - Newspaper/Magazine Article
The hospital ran out of her child's cancer drug. Now she's fighting to end shortages.
Citation Text:
The hospital ran out of her child's cancer drug. Now she's fighting to end shortages. Noguchi Y. Health Shots and All Things Considered. National Public Ra…