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psnet.ahrq.gov/issue/health-care-associated-infections-meta-analysis-costs-and-financial-impact-us-health-care
July 31, 2013 - Study
Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system.
Citation Text:
Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JA…
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psnet.ahrq.gov/issue/massive-open-online-course-mooc-learning-builds-capacity-and-improves-competence-patient
October 14, 2020 - Study
Massive open online course (MOOC) learning builds capacity and improves competence for patient safety among global learners: a prospective cohort study.
Citation Text:
Gleason KT, Commodore-Mensah Y, Wu AW, et al. Massive open online course (MOOC) learning builds capacity and impro…
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psnet.ahrq.gov/issue/171-billion-problem-annual-cost-measurable-medical-errors
May 26, 2021 - Study
Classic
The $17.1 billion problem: the annual cost of measurable medical errors.
Citation Text:
Van Den Bos J, Rustagi K, Gray T, et al. The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors. Health Aff. 2011;30(4):596-603. doi:10.1377/hl…
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psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based
April 08, 2018 - Study
Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample.
Citation Text:
Newman-Toker DE, Moy E, Valente E, et al. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-b…
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psnet.ahrq.gov/issue/symptom-disease-pair-analysis-diagnostic-error-spade-conceptual-framework-and-methodological
October 23, 2019 - Review
Classic
Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data.
Citation Text:
Liberman AL, Newman-Toker DE. Symptom-Disease Pair Analysis of D…
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psnet.ahrq.gov/issue/analysis-clinical-decision-support-system-malfunctions-case-series-and-survey
April 29, 2018 - Study
Analysis of clinical decision support system malfunctions: a case series and survey.
Citation Text:
Wright A, Hickman T-TT, McEvoy D, et al. Analysis of clinical decision support system malfunctions: a case series and survey. J Am Med Inform Assoc. 2016;23(6):1068-1076. doi:10.1093…
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psnet.ahrq.gov/node/36216/psn-pdf
August 03, 2012 - Hospital Medication Errors Commonplace.
August 3, 2012
Berwick D; Lassman S; Bates D. National Public Radio. July 28, 2006.
https://psnet.ahrq.gov/issue/hospital-medication-errors-commonplace
This segment features Donald Berwick, David Bates, and other experts discussing the Institute of Medicine
(IOM) report Prev…
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psnet.ahrq.gov/node/42072/psn-pdf
August 03, 2016 - Innovation in Perioperative Patient Safety.
August 3, 2016
Miller DR, Merry AF, eds. Can J Anesth. 2013;60(2):7-220.
https://psnet.ahrq.gov/issue/innovation-perioperative-patient-safety
Articles in this special issue discuss strategies to improve safety in anesthesia, including simulation
training, perioperative c…
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psnet.ahrq.gov/node/38233/psn-pdf
March 03, 2010 - The Science of Simulation in Healthcare: Defining and
Developing Clinical Expertise.
March 3, 2010
Kaji AH, Cone DC, eds. Acad Emerg Med. 2008;15:971-1222.
https://psnet.ahrq.gov/issue/science-simulation-healthcare-defining-and-developing-clinical-expertise
This special issue highlights an AHRQ-funded sympo…
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psnet.ahrq.gov/node/34016/psn-pdf
July 03, 2013 - Profiles in patient safety: authority gradients in medical
error.
July 3, 2013
Cosby K, Croskerry P. Profiles in patient safety: authority gradients in medical error. Acad Emerg Med.
2004;11(12):1341-5.
https://psnet.ahrq.gov/issue/profiles-patient-safety-authority-gradients-medical-error
The authors apply the av…
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psnet.ahrq.gov/node/40086/psn-pdf
December 15, 2010 - The Safe Use Initiative and Health Literacy: Workshop
Summary.
December 15, 2010
Vancheri C; Roundtable on Health Literacy; Institute of Medicine. Washington, DC: National Academies
Press; 2010. ISBN-10: 0309159318.
https://psnet.ahrq.gov/issue/safe-use-initiative-and-health-literacy-workshop-summary
This publica…
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psnet.ahrq.gov/node/42756/psn-pdf
November 20, 2013 - Removing the "me" from "MD."
November 20, 2013
Parikh RB. Removing the “Me” From “MD”. JAMA. 2013;310(18). doi:10.1001/jama.2013.280722.
https://psnet.ahrq.gov/issue/removing-me-md
Recounting what one medical student learned by shadowing a nurse, this commentary emphasizes the
importance of interprofessional commu…
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psnet.ahrq.gov/node/35967/psn-pdf
January 02, 2017 - Physician perception of hospital safety and barriers to
incident reporting.
January 2, 2017
Schectman JM, Plews-Ogan M. Physician perception of hospital safety and barriers to incident reporting. Jt
Comm J Qual Patient Saf. 2006;32(6):337-43.
https://psnet.ahrq.gov/issue/physician-perception-hospital-safety-and-ba…
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psnet.ahrq.gov/node/34598/psn-pdf
November 15, 2011 - Complexity and the Adoption of Innovation in Health
Care.
November 15, 2011
Plsek P. Washington DC: National Institute for Health Care Management Foundation and National
Committee for Quality Health Care; 2003.
https://psnet.ahrq.gov/issue/complexity-and-adoption-innovation-health-care
In discussing the complexit…
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psnet.ahrq.gov/node/33968/psn-pdf
July 08, 2016 - Health Literacy: A Prescription to End Confusion.
July 8, 2016
Nielsen-Bohlman L; Panzer AM; Kindig DA; Board on Neuroscience and Behavioral Health, Institute of
Medicine. Washington, DC: The National Academies Press; 2004. ISBN: 9780309283328.
https://psnet.ahrq.gov/issue/health-literacy-prescription-end-confusion…
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psnet.ahrq.gov/node/42480/psn-pdf
August 07, 2013 - A multi-tiered approach to safety education.
August 7, 2013
Oates K, Sammut J, Kennedy P. A multi-tiered approach to safety education. Clin Teach. 2013;10(4):214-
8. doi:10.1111/tct.12037.
https://psnet.ahrq.gov/issue/multi-tiered-approach-safety-education
This commentary describes an initiative that incorporated …
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psnet.ahrq.gov/node/35608/psn-pdf
July 05, 2013 - Battling the obstetric malpractice crisis: improving
patient safety, part 2.
July 5, 2013
Bernstein PS.
https://psnet.ahrq.gov/issue/battling-obstetric-malpractice-crisis-improving-patient-safety-part-2
This article addresses systems issues that need to be resolved in order to improve the safety of obstetric
care…
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psnet.ahrq.gov/node/39200/psn-pdf
March 28, 2010 - Creating champions for health care quality and safety.
March 28, 2010
Holland R, Meyers D, Hildebrand C, et al. Creating champions for health care quality and safety. Am J Med
Qual. 2010;25(2):102-108. doi:10.1177/1062860609352108.
https://psnet.ahrq.gov/issue/creating-champions-health-care-quality-and-safety
Inte…
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psnet.ahrq.gov/node/43035/psn-pdf
October 12, 2018 - Patient's Toolkit for Diagnosis.
October 12, 2018
SIDM Patient Engagement Committee. Evanston, IL: Society to Improve Diagnosis in Medicine; October
2018.
https://psnet.ahrq.gov/issue/patients-toolkit-diagnosis
Patient engagement has been promoted as a strategy to enhance safety in health care. This toolkit helps
…
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psnet.ahrq.gov/node/37642/psn-pdf
March 26, 2008 - Medication, allergy, and adverse drug event
discrepancies in ambulatory care.
March 26, 2008
Stephens M, Fox B, Kukulka G, et al. Medication, allergy, and adverse drug event discrepancies in
ambulatory care. Fam Med. 2008;40(2):107-10.
https://psnet.ahrq.gov/issue/medication-allergy-and-adverse-drug-event-discrepa…