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psnet.ahrq.gov/issue/biased-language-simulated-handoffs-and-clinician-recall-and-attitudes
June 29, 2022 - Study
Biased language in simulated handoffs and clinician recall and attitudes.
Citation Text:
Wesevich A, Langan E, Fridman I, et al. Biased language in simulated handoffs and clinician recall and attitudes. JAMA Netw Open. 2024;7(12):e2450172. doi:10.1001/jamanetworkopen.2024.50172.
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psnet.ahrq.gov/issue/communication-failure-analysis-prescribers-use-internal-free-text-field-electronic
May 20, 2019 - Study
Communication failure: analysis of prescribers' use of an internal free-text field on electronic prescriptions.
Citation Text:
Ai A, Wong A, Amato MG, et al. Communication failure: analysis of prescribers’ use of an internal free-text field on electronic prescriptions. J Am Med Inf…
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psnet.ahrq.gov/issue/preferences-and-perceptions-medical-error-disclosure-among-marginalized-populations-narrative
June 15, 2022 - Review
Preferences and perceptions of medical error disclosure among marginalized populations: a narrative review.
Citation Text:
Olazo K, Wang K, Sierra M, et al. Preferences and perceptions of medical error disclosure among marginalized populations: a narrative review. Jt Comm J Qual P…
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psnet.ahrq.gov/issue/minor-flow-disruptions-traffic-related-factors-and-their-effect-major-flow-disruptions
August 19, 2020 - Study
Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room.
Citation Text:
Joseph A, Khoshkenar A, Taaffe KM, et al. Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating roo…
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psnet.ahrq.gov/issue/deficiencies-facility-leaders-response-critical-surgical-events-michael-e-debakey-va-medical
November 29, 2023 - Book/Report
Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.
Citation Text:
Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, …
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psnet.ahrq.gov/issue/nurse-staffing-and-inpatient-hospital-mortality
June 22, 2022 - Study
Classic
Nurse staffing and inpatient hospital mortality.
Citation Text:
Needleman J, Buerhaus P, Pankratz S, et al. Nurse staffing and inpatient hospital mortality. New Engl J Med. 2011;364(11):1037-1045. doi:10.1056/NEJMsa1001025.
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Fo…
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psnet.ahrq.gov/issue/perfect-storm-exam-medical-error-and-factors-contributing-its-possible-escalation
October 20, 2021 - Commentary
The perfect storm: exam of a medical error and factors contributing to its possible escalation.
Citation Text:
Walters GK. The perfect storm: exam of a medical error and factors contributing to its possible escalation. J Patient Saf. 2021;17(4):e264-e267. doi:10.1097/pts.00000…
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psnet.ahrq.gov/issue/effect-facility-complexity-perceptions-safety-climate-operating-room-size-matters
December 21, 2014 - Study
The effect of facility complexity on perceptions of safety climate in the operating room: size matters.
Citation Text:
Carney BT, West P, Neily J, et al. The effect of facility complexity on perceptions of safety climate in the operating room: size matters. Am J Med Qual. 2010;25…
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psnet.ahrq.gov/issue/recommendations-improve-usability-drug-drug-interaction-clinical-decision-support-alerts
February 14, 2024 - Commentary
Recommendations to improve the usability of drug–drug interaction clinical decision support alerts.
Citation Text:
Payne TH, Hines LE, Chan RC, et al. Recommendations to improve the usability of drug-drug interaction clinical decision support alerts. J Am Med Inform Assoc. 201…
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psnet.ahrq.gov/issue/analysis-critical-incident-reports-using-natural-language-processing
June 14, 2023 - Study
Analysis of critical incident reports using natural language processing.
Citation Text:
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.
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Format:
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psnet.ahrq.gov/node/35162/psn-pdf
November 29, 2009 - Fair and Reliable Medical Justice Act.
November 29, 2009
Enzi M; Baucus M.
https://psnet.ahrq.gov/issue/fair-and-reliable-medical-justice-act
This bill was introduced in the U.S. Senate to encourage alternatives to the current medical malpractice
system (by creating a "health care court") and to promote early disc…
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psnet.ahrq.gov/node/36230/psn-pdf
June 13, 2011 - Hospitals put emphasis on collection of medication data.
June 13, 2011
Krizner K. Managed Healthcare Executive. August 1, 2006.
https://psnet.ahrq.gov/issue/hospitals-put-emphasis-collection-medication-data
This article describes several hospital-based medication reconciliation efforts.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/37206/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR; Smetzer JL.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-17
This monthly selection of medication error reports discusses problems related to intravenous tubing
misconnections, unidentified medication patches, and after-hours pharm…
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psnet.ahrq.gov/node/37282/psn-pdf
September 27, 2016 - Verbal medication orders in the OR.
September 27, 2016
Hendrickson T. Verbal medication orders in the OR. AORN J. 2007;86(4):626-9.
https://psnet.ahrq.gov/issue/verbal-medication-orders-or
This article describes the causes of medication errors in the operating room and discusses prevention
strategies, including us…
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psnet.ahrq.gov/node/46890/psn-pdf
December 21, 2018 - Physician burnout, well-being, and work unit safety
grades in relationship to reported medical errors.
December 21, 2018
Tawfik DS, Profit J, Morgenthaler TI, et al. Physician Burnout, Well-being, and Work Unit Safety Grades in
Relationship to Reported Medical Errors. Mayo Clin Proc. 2018;93(11):1571-1580.
doi:10.…
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psnet.ahrq.gov/node/38642/psn-pdf
April 30, 2012 - ASHP national survey of pharmacy practice in hospital
settings: dispensing and administration—2008.
April 30, 2012
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital
settings: dispensing and administration--2008. Am J Health Syst Pharm. 2009;66(10):926-46.
doi:10.2146…
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psnet.ahrq.gov/node/47908/psn-pdf
April 24, 2019 - "Sorry" is never enough: how state apology laws fail to
reduce medical malpractice liability risk.
April 24, 2019
McMichael BJ, Van Horn L, Viscusi K. "Sorry” Is Never Enough: How State Apology Laws Fail to Reduce
Medical Malpractice Liability Risk. Stanford Law Rev. 2019;71(2):341-409.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/39947/psn-pdf
July 03, 2014 - Association between implementation of a medical team
training program and surgical mortality.
July 3, 2014
Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training
program and surgical mortality. JAMA. 2010;304(15):1693-1700. doi:10.1001/jama.2010.1506.
https://psnet.ahrq…
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psnet.ahrq.gov/node/45863/psn-pdf
August 28, 2017 - Large-scale implementation of the I-PASS handover
system at an academic medical centre.
August 28, 2017
Shahian DM, McEachern K, Rossi L, et al. Large-scale implementation of the I-PASS handover system at
an academic medical centre. BMJ Qual Saf. 2017;26(9):760-770. doi:10.1136/bmjqs-2016-006195.
https://psnet.ahr…
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psnet.ahrq.gov/node/38805/psn-pdf
April 04, 2011 - Disclosing medical errors to patients: it's not what you
say, it's what they hear.
April 4, 2011
Wu AW, Huang I-C, Stokes S, et al. Disclosing medical errors to patients: it's not what you say, it's what
they hear. J Gen Intern Med. 2009;24(9):1012-7. doi:10.1007/s11606-009-1044-3.
https://psnet.ahrq.gov/issue/dis…