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psnet.ahrq.gov/node/47542/psn-pdf
January 16, 2019 - Utilizing a Systems and Design Thinking Approach for
Improving Well-Being Within Health Professional
Education and Health Care.
January 16, 2019
Kreitzer MJ, Carter K, Coffey DS, et al. NAM Perspectives. Washington, DC: National Academy of
Medicine; 2019.
https://psnet.ahrq.gov/issue/utilizing-systems-and-design-…
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psnet.ahrq.gov/node/837765/psn-pdf
August 03, 2022 - Pediatric musculoskeletal radiographs: anatomy and
fractures prone to diagnostic error among emergency
physicians.
August 3, 2022
Li W, Stimec J, Camp M, et al. Pediatric musculoskeletal radiographs: anatomy and fractures prone to
diagnostic error among emergency physicians. J Emerg Med. 2022;62(4):524-533.
doi:1…
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psnet.ahrq.gov/node/48076/psn-pdf
July 24, 2019 - Simulation-based event analysis improves error
discovery and generates improved strategies for error
prevention.
July 24, 2019
Lobos A-T, Ward N, Farion KJ, et al. Simulation-based event analysis improves error discovery and
generates improved strategies for error prevention. Simul Healthc. 2019;14(4):209-216.
do…
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psnet.ahrq.gov/node/43774/psn-pdf
March 06, 2015 - A prospective cohort study of medication reconciliation
using pharmacy technicians in the emergency department
to reduce medication errors among admitted patients.
March 6, 2015
Cater SW, Luzum M, Serra AE, et al. A prospective cohort study of medication reconciliation using
pharmacy technicians in the emergency d…
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psnet.ahrq.gov/node/838185/psn-pdf
September 28, 2022 - How to mitigate the effects of cognitive biases during
patient safety incident investigations.
September 28, 2022
Rogers JE, Hilgers TR, Keebler JR, et al. How to mitigate the effects of cognitive biases during patient
safety incident investigations. Jt Comm J Qual Patient Saf. 2022;48(11):612-616.
doi:10.1016/j.j…
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psnet.ahrq.gov/node/45617/psn-pdf
November 30, 2016 - Walking a tightrope: balancing the risk of diagnostic error
in inpatient pediatrics.
November 30, 2016
Berkwitt A, Osborn R, Grossman M. Walking a Tightrope: Balancing the Risk of Diagnostic Error in
Inpatient Pediatrics. Hosp Pediatr. 2016;6(9):566-8. doi:10.1542/hpeds.2016-0043.
https://psnet.ahrq.gov/issue/walk…
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psnet.ahrq.gov/node/46132/psn-pdf
September 24, 2017 - The "Quality Minute"—a new, brief, and structured
technique for quality improvement education during the
morbidity and mortality conference.
September 24, 2017
Hoffman RL, Morris JB, Kelz RR. The “Quality Minute”—A New, Brief, and Structured Technique for Quality
Improvement Education During the Morbidity and Mort…
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psnet.ahrq.gov/node/44225/psn-pdf
June 17, 2015 - Do No Harm: Stories of Life, Death, and Brain Surgery.
June 17, 2015
Marsh H. New York, NY: Thomas Dunne Books; 2015. ISBN: 9781250065810.
https://psnet.ahrq.gov/issue/do-no-harm-stories-life-death-and-brain-surgery
This intensely personal memoir by the famed British neurosurgeon Henry Marsh is no hagiography or
r…
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psnet.ahrq.gov/node/47659/psn-pdf
January 27, 2019 - Medical overuse as a physician cognitive error: looking
under the hood.
January 27, 2019
Korenstein D. Medical overuse as a physician cognitive error: looking under the hood. JAMA Intern Med.
2019;179(1):26-27. doi:10.1001/jamainternmed.2018.5136.
https://psnet.ahrq.gov/issue/medical-overuse-physician-cognitive-er…
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psnet.ahrq.gov/node/36698/psn-pdf
February 24, 2011 - The impact of duty hours on resident self reports of
errors.
February 24, 2011
Vidyarthi A, Auerbach AD, Wachter R, et al. The impact of duty hours on resident self reports of errors. J
Gen Intern Med. 2007;22(2):205-9.
https://psnet.ahrq.gov/issue/impact-duty-hours-resident-self-reports-errors
Residency programs…
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psnet.ahrq.gov/node/45983/psn-pdf
June 27, 2018 - Educating for the 21st-century health care system: an
interdependent framework of basic, clinical, and systems
sciences.
June 27, 2018
Gonzalo JD, Haidet P, Papp KK, et al. Educating for the 21st-Century Health Care System: An
Interdependent Framework of Basic, Clinical, and Systems Sciences. Acad Med. 2017;92(1):…
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psnet.ahrq.gov/node/46601/psn-pdf
January 25, 2018 - Night-time communication at Stanford University
Hospital: perceptions, reality and solutions.
January 25, 2018
Sun AJ, Wang L, Go M, et al. Night-time communication at Stanford University Hospital: perceptions, reality
and solutions. BMJ Qual Saf. 2018;27(2):156-162. doi:10.1136/bmjqs-2017-006727.
https://psnet.ah…
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psnet.ahrq.gov/node/50798/psn-pdf
January 15, 2020 - Testing alertness of emergency physicians: a novel
quantitative measure of alertness and implications for
worker and patient care.
January 15, 2020
Ferguson BA, Lauriski DR, Huecker M, et al. Testing Alertness of Emergency Physicians: A Novel
Quantitative Measure of Alertness and Implications for Worker and Patien…
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psnet.ahrq.gov/node/42840/psn-pdf
January 08, 2014 - A system-wide approach to explaining variation in
potentially avoidable emergency admissions: national
ecological study.
January 8, 2014
O'Cathain A, Knowles E, Maheswaran R, et al. A system-wide approach to explaining variation in
potentially avoidable emergency admissions: national ecological study. BMJ Qual Saf…
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psnet.ahrq.gov/node/43634/psn-pdf
November 05, 2014 - Safety in numbers: lack of evidence to indicate the
number of physicians needed to provide safe acute
medical care.
November 5, 2014
Sabin J, Subbe CP, Vaughan L, et al. Safety in numbers: lack of evidence to indicate the number of
physicians needed to provide safe acute medical care. Clin Med (Lond). 2014;14(5):4…
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psnet.ahrq.gov/node/47568/psn-pdf
March 06, 2019 - Trends in anesthesia-related liability and lessons learned.
March 6, 2019
Mora JC, Kaye AD, Romankowski ML, et al. Trends in Anesthesia-Related Liability and Lessons Learned.
Adv Anesth. 2018;36(1):231-249. doi:10.1016/j.aan.2018.07.009.
https://psnet.ahrq.gov/issue/trends-anesthesia-related-liability-and-lessons-l…
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psnet.ahrq.gov/node/836859/psn-pdf
April 06, 2022 - Choosing wisely in clinical practice: embracing critical
thinking, striving for safer care.
April 6, 2022
Furlan L, Francesco PD, Costantino G, et al. Choosing wisely in clinical practice: embracing critical
thinking, striving for safer care. J Intern Med. 2022;291(4):397-407. doi:10.1111/joim.13472.
https://psnet…
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psnet.ahrq.gov/node/44314/psn-pdf
November 06, 2015 - Unintentional discontinuation of chronic medications for
seniors in nursing homes: evaluation of a national
medication reconciliation accreditation requirement using
a population-based cohort study.
November 6, 2015
Stall NM, Fischer HD, Wu F, et al. Unintentional Discontinuation of Chronic Medications for Seniors…
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psnet.ahrq.gov/node/837332/psn-pdf
June 08, 2022 - Influence of psychological safety and organizational
support on the impact of humiliation on trainee well-
being.
June 8, 2022
Appelbaum NP, Santen SA, Perera RA, et al. Influence of psychological safety and organizational support
on the impact of humiliation on trainee well-being. J Patient Saf. 2022;18(4):370-37…
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psnet.ahrq.gov/node/44430/psn-pdf
October 28, 2015 - The role of dynamic trade-offs in creating safety—a
qualitative study of handover across care boundaries in
emergency care.
October 28, 2015
Sujan M, Spurgeon P, Cooke M. The role of dynamic trade-offs in creating safety—A qualitative study of
handover across care boundaries in emergency care. Reliab Eng Syst Saf.…