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psnet.ahrq.gov/issue/medication-reconciliation-academic-medical-center-implementation-comprehensive-program
April 24, 2018 - Commentary
Medication reconciliation at an academic medical center: implementation … Medication reconciliation at an academic medical center: implementation of a comprehensive program from … Medication reconciliation at an academic medical center: implementation of a comprehensive program from … August 25, 2010
A virtual breakthrough series collaborative for missed test results: … Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical
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psnet.ahrq.gov/issue/two-words-can-soothe-patients-who-have-been-harmed-were-sorry
July 26, 2017 - This news article reports on two incidents involving medical errors—one demonstrating the traditional … December 20, 2017
Electronic medicine can send you test results quickly. … March 13, 2013
Five simple steps to avoid becoming a medical mystery. … April 25, 2016
Dealing with a medical mistake: should physicians apologize to patients … June 5, 2013
Medical malpractice: why is it so hard for doctors to apologize?
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psnet.ahrq.gov/issue/biggest-mistake-doctors-make
October 09, 2013 - article describes efforts to prevent diagnostic errors , including improving follow-up of abnormal test … January 13, 2016
A medical detective story: why doctors make diagnostic errors. … October 23, 2018
Why hospitals still make serious medical errors—and how they are trying … March 29, 2023
Health-care providers want patients to read medical records, spot errors
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psnet.ahrq.gov/issue/extent-and-importance-unintended-consequences-related-computerized-provider-order-entry
May 27, 2011 - May 20, 2019
Timely follow-up of abnormal diagnostic imaging test results in an outpatient … setting: are electronic medical records achieving their potential? … April 4, 2011
Notification of abnormal lab test results in an electronic medical record
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psnet.ahrq.gov/issue/nurses-guilty-verdict-dosing-mistake-could-cost-lives
April 27, 2022 - Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patient … A just culture centers on moving from blaming individuals for medical errors towards a systems-based … September 28, 2022
Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2022 … May 5, 2021
A biased test kept thousands of Black people from getting a kidney transplant … March 1, 2023
Nurse Vaught sentenced for deadly medical error.
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psnet.ahrq.gov/issue/harmed-patients-gaining-voice-challenging-dominant-perspectives-construction-medical-harm-and
March 18, 2020 - Harmed patients gaining voice: challenging dominant perspectives in the construction of medical … Harmed patients gaining voice: challenging dominant perspectives in the construction of medical harm … Harmed patients gaining voice: challenging dominant perspectives in the construction of medical harm … December 19, 2014
Test result communication in primary care: clinical and office staff
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psnet.ahrq.gov/issue/preventing-diagnostic-errors-ambulatory-care-electronic-notification-tool-incomplete
April 22, 2013 - To fully appreciate the implications of missed test notifications to reduce the risk of delayed diagnoses … April 22, 2013
Comparing patient-reported hospital adverse events with medical record … 2010
Association of open communication and the emotional and behavioural impact of medical … July 16, 2014
Development of a tool within the electronic medical record to facilitate
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psnet.ahrq.gov/issue/measuring-and-improving-patient-safety-through-health-information-technology-health-it-safety
December 06, 2023 - 2023
Application of human factors methods to understand missed follow-up of abnormal test … July 1, 2017
Electronic detection of delayed test result follow-up in patients with hypothyroidism … Assessment of the use of patient vital sign data for preventing misidentification and medical
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psnet.ahrq.gov/issue/toward-more-proactive-approaches-safety-electronic-health-record-era
December 06, 2023 - 2023
Application of human factors methods to understand missed follow-up of abnormal test … July 1, 2017
Electronic detection of delayed test result follow-up in patients with hypothyroidism … December 6, 2017
The evolving role of medical scribe: variation and implications for
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psnet.ahrq.gov/issue/diagnostic-concordance-among-pathologists-interpreting-breast-biopsy-specimens
July 13, 2016 - Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical … Screening Tool: Delayed Treatment
September 1, 2017
Communicating Critical Test … December 27, 2014
Point-of-care testing, medical error, and patient safety: a 2007 assessment … Hospitals
Health Care Executives and Administrators
Pathology and Laboratory Medicine
Diagnostic Test
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psnet.ahrq.gov/issue/adopting-electronic-medical-records-primary-care-lessons-learned-health-information-systems
January 07, 2015 - Review
Adopting electronic medical records in primary care: lessons learned from … Adopting electronic medical records in primary care: lessons learned from health information systems … Adopting electronic medical records in primary care: lessons learned from health information systems … July 16, 2015
Findings of the first consensus conference on medical emergency teams. … April 21, 2011
Management of test results in family medicine offices.
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psnet.ahrq.gov/issue/new-argument-no-fault-compensation-health-care-introduction-artificial-intelligence-systems
May 13, 2020 - legal experts will need to consider how to manage compensation for patients who have experienced medical … September 16, 2020
Closing the loop on test results to reduce communication failures: … View More
Related Resources
Digital health technology-specific risks for medical … October 19, 2022
The deterrent effect of tort law: evidence from medical malpractice … July 8, 2020
The social cost of adverse medical events, and what we can do about it.
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psnet.ahrq.gov/issue/tempos-management-primary-care-key-factor-classifying-adverse-events-and-improving-quality
March 15, 2017 - complaints and adherence to recommendations), office tempo (including the availability of clinicians and test … August 8, 2010
The management of test results in primary care: does an electronic medical
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psnet.ahrq.gov/primer/diagnostic-errors
June 15, 2024 - In the Harvard Medical Practice Study , diagnostic error accounted for 17% of preventable errors in … Blind obedience Placing undue reliance on test results or "expert" opinion A false-negative rapid test … outpatient clinical situations, such as triaging acutely ill patients by telephone and following up on test … establishing a work system and safety culture that foster timely and accurate diagnosis, improving the medical
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - guidelines suggest that breast radiologists should palpate any identified mass and consider the pre-test … While closed-loop test result management is a robust intervention embedded in many commercial electronic … Relying on official test reports may convey a false sense of security, under-estimating risk, and over-estimating … Weingart, MD, MPP, PhD
Chief Medical Officer
Tufts Medical Center
Gordon D. … WebM&M Cases
A Postpartum Woman with an Erroneous SARS-CoV-2 Test
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psnet.ahrq.gov/issue/eu-tackle-issue-patient-safety
September 06, 2023 - This news extra from the British Medical Journal reports that European governments and health professionals … The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical … September 4, 2024
Patient safety in actioning and communicating blood test results in … November 30, 2007
Medical errors still claiming many lives.
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psnet.ahrq.gov/issue/doctors-quest-piece-together-american-health-care
October 05, 2022 - Disjointed health care processes contribute to missed test results , incomplete communication, and … June 10, 2015
Medical disrespect. … March 6, 2024
The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making
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psnet.ahrq.gov/issue/physician-burnout
May 01, 2017 - highlights AHRQ-supported research to examine burnout in health care as well as efforts to develop and test … August 1, 2012
Advances in Patient Safety and Medical Liability. … September 27, 2023
Medical Office Survey: 2020 User Database Report. … May 30, 2018
Medical Office Survey on Patient Safety Culture: 2018 User Database Report
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psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root-cause-analysis
August 28, 2024 - Errors occurred in all three states of the test cycle. … April 30, 2014
Medical team training: applying crew resource management in the Veterans … August 20, 2018
Safety climate and medical errors in 62 US emergency departments.
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psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - examination are twofold: first, there is time delay (often a day or two) in diagnosis as one awaits the test … Skilled clinicians test the candidate at the bedside on real patients to see if they can sort out valvular … with recent test takers, tests everything but the kind of true clinical skills that are tested in other … countries; it does little to test the ability of the candidate to palpate an enlarged spleen or detect … Medical Institutions.