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psnet.ahrq.gov/node/45670/psn-pdf
November 16, 2016 - Not thinking clearly? Play a game, seriously!
November 16, 2016
Mohan D, Schell J, Angus DC. Not Thinking Clearly? Play a Game, Seriously!. JAMA. 2016;316(18):1867-
1868. doi:10.1001/jama.2016.14174.
https://psnet.ahrq.gov/issue/not-thinking-clearly-play-game-seriously
Heuristics enable experts to build off their …
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psnet.ahrq.gov/node/48070/psn-pdf
July 17, 2019 - Controversies in diagnosis: contemporary debates in the
diagnostic safety literature.
July 17, 2019
Bergl PA, Wijesekera TP, Nassery N, et al. Controversies in diagnosis: contemporary debates in the
diagnostic safety literature. Diagnosis (Berl). 2020;7(1):3-9. doi:10.1515/dx-2019-0016.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/60753/psn-pdf
August 05, 2020 - A qualitative exploration of mental health service user
and carer perspectives on safety issues in UK mental
health services.
August 5, 2020
Berzins K, Baker J, Louch G, et al. A qualitative exploration of mental health service user and carer
perspectives on safety issues in UK mental health services. Health Expec…
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psnet.ahrq.gov/node/838193/psn-pdf
September 28, 2022 - Economics of Medication Safety. Improving Medication
Safety Through Collective, Real-time Learning.
September 28, 2022
de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and
Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.
…
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psnet.ahrq.gov/node/43257/psn-pdf
August 14, 2014 - Barriers and success factors to the implementation of a
multi-site prospective adverse event surveillance system.
August 14, 2014
Backman C, Forster AJ, Vanderloo S. Barriers and success factors to the implementation of a multi-site
prospective adverse event surveillance system. Int J Qual Health Care. 2014;26(4):4…
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psnet.ahrq.gov/node/73864/psn-pdf
September 22, 2021 - Simulation-based assessment identifies longitudinal
changes in cognitive skills in an anesthesiology
residency training program.
September 22, 2021
Sidi A, Gravenstein N, Vasilopoulos T, et al. Simulation-based assessment identifies longitudinal changes
in cognitive skills in an anesthesiology residency training p…
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psnet.ahrq.gov/node/43744/psn-pdf
December 03, 2014 - Mobile physician reporting of clinically significant
events—a novel way to improve handoff communication
and supervision of resident on call activities.
December 3, 2014
Nabors C, Peterson SJ, Aronow WS, et al. Mobile physician reporting of clinically significant events-a novel
way to improve handoff communication…
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psnet.ahrq.gov/node/43580/psn-pdf
October 01, 2014 - Reducing medication errors in critical care: a multimodal
approach.
October 1, 2014
Kruer RM, Jarrell AS, Latif A. Reducing medication errors in critical care: a multimodal approach. Clin
Pharmacol. 2014;6:117-26. doi:10.2147/CPAA.S48530.
https://psnet.ahrq.gov/issue/reducing-medication-errors-critical-care-multim…
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psnet.ahrq.gov/node/47773/psn-pdf
April 17, 2019 - People, systems and safety: resilience and excellence in
healthcare practice.
April 17, 2019
Smith AF, Plunkett E. People, systems and safety: resilience and excellence in healthcare practice.
Anaesthesia. 2019;74(4):508-517. doi:10.1111/anae.14519.
https://psnet.ahrq.gov/issue/people-systems-and-safety-resilience…
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psnet.ahrq.gov/node/72602/psn-pdf
December 23, 2020 - Patient safety in chiropractic teaching programs: a mixed
methods study.
December 23, 2020
Pohlman KA, Salsbury SA, Funabashi M, et al. Patient safety in chiropractic teaching programs: a mixed
methods study. Chiropr Man Therap. 2020;28(1):50. doi:10.1186/s12998-020-00339-0.
https://psnet.ahrq.gov/issue/patient-sa…
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psnet.ahrq.gov/node/866955/psn-pdf
October 16, 2024 - Adverse diagnostic events in hospitalised patients: a
single-centre, retrospective cohort study.
October 16, 2024
Dalal AK, Plombon S, Konieczny K, et al. Adverse diagnostic events in hospitalised patients: a single-
centre, retrospective cohort study. BMJ Qual Saf. 2024;Epub Oct 1. doi:10.1136/bmjqs-2024-017183.
…
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psnet.ahrq.gov/node/35850/psn-pdf
May 27, 2011 - Computerization can create safety hazards: a bar-coding
near miss.
May 27, 2011
McDonald CJ. Computerization can create safety hazards: a bar-coding near miss. Ann Intern Med.
2006;144(7):510-6.
https://psnet.ahrq.gov/issue/computerization-can-create-safety-hazards-bar-coding-near-miss
This case study shares the …
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psnet.ahrq.gov/node/46474/psn-pdf
November 08, 2017 - Clearing the Error: Using Public Deliberation to Define
Patient Roles as Partners in the Diagnostic Process.
November 8, 2017
St. Paul, MN: Society to Improve Diagnosis in Medicine, Maxwell School of Citizenship and Public Affairs at
Syracuse University, and Jefferson Center; 2017.
https://psnet.ahrq.gov/issue/cle…
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psnet.ahrq.gov/node/60005/psn-pdf
March 04, 2020 - What if?: Transforming Diagnostic Research by
Leveraging a Diagnostic Process Map to Engage Patients
in Learning from Errors.
March 4, 2020
Sheridan S, Merryweather P, Rusz D, et al. What If?: Transforming Diagnostic Research By Leveraging A
Diagnostic Process Map To Engage Patients In Learning From Errors. Washin…
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psnet.ahrq.gov/node/837068/psn-pdf
May 11, 2022 - Barriers and enablers to nurses' use of harm prevention
strategies for older patients in hospital: a cross-sectional
survey.
May 11, 2022
Redley B, Taylor N, Hutchinson A. Barriers and enablers to nurses' use of harm prevention strategies for
older patients in hospital: a cross?sectional survey. J Adv Nurs. 2022;7…
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psnet.ahrq.gov/node/43870/psn-pdf
January 28, 2015 - Peer review of medical practices: missed opportunities to
learn.
January 28, 2015
Kadar N. Peer review of medical practices: missed opportunities to learn. Am J Obstet Gynecol.
2014;211(6):596-601. doi:10.1016/j.ajog.2014.08.018.
https://psnet.ahrq.gov/issue/peer-review-medical-practices-missed-opportunities-learn…
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psnet.ahrq.gov/node/43038/psn-pdf
March 05, 2014 - Missed it.
March 5, 2014
Green MJ, Rieck R. Missed it. Ann Intern Med. 2013;158(5 Pt 1):357-61. doi:10.7326/0003-4819-158-5-
201303050-00013.
https://psnet.ahrq.gov/issue/missed-it-0
This piece uses a graphic novel format to depict a story of a diagnostic error that resulted in a patient’s
death. The attention-gr…
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psnet.ahrq.gov/node/846147/psn-pdf
March 15, 2023 - Automated capture of intraoperative adverse events using
artificial intelligence: a systematic review and meta-
analysis.
March 15, 2023
Eppler MB, Sayegh AS, Maas M, et al. Automated capture of intraoperative adverse events using artificial
intelligence: a systematic review and meta-analysis. J Clin Med. 2023;12(…
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psnet.ahrq.gov/node/867380/psn-pdf
December 18, 2024 - Cognitive biases and artificial intelligence.
December 18, 2024
Wang J, Redelmeier DA. Cognitive biases and artificial intelligence. NEJM AI. 2024;1(12):AIcs2400639.
doi:10.1056/aics2400639.
https://psnet.ahrq.gov/issue/cognitive-biases-and-artificial-intelligence
Previous studies have raised concerns about cognit…
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psnet.ahrq.gov/node/47595/psn-pdf
March 06, 2019 - Approaches and Challenges to Electronically Matching
Patients' Records Across Providers.
March 6, 2019
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
https://psnet.ahrq.gov/issue/approaches-and-challenges-electronically-matching-patients-records-across-
provid…