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psnet.ahrq.gov/node/41490/psn-pdf
August 07, 2012 - 2011 John M. Eisenberg Patient Safety and Quality
Awards.
August 7, 2012
Jt Comm J Qual Patient Saf. 2012;38(7):289-327.
https://psnet.ahrq.gov/issue/2011-john-m-eisenberg-patient-safety-and-quality-awards
Highlighting the accomplishments of the 2011 recipients of the John M. Eisenberg Patient Safety and
Quality …
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psnet.ahrq.gov/node/44905/psn-pdf
April 27, 2016 - Inpatient housestaff discontinuity of care and patient
adverse events.
April 27, 2016
Fletcher KE, Singh S, Schapira MM, et al. Inpatient Housestaff Discontinuity of Care and Patient Adverse
Events. Am J Med. 2016;129(3):341-7.e21. doi:10.1016/j.amjmed.2015.11.008.
https://psnet.ahrq.gov/issue/inpatient-housestaff…
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psnet.ahrq.gov/node/47364/psn-pdf
October 31, 2018 - AI can't replace doctors. But it can make them better.
October 31, 2018
Parikh R. MIT Technol Rev. October 23, 2018.
https://psnet.ahrq.gov/issue/ai-cant-replace-doctors-it-can-make-them-better
Computerized decision support and artificial intelligence (AI) are being utilized to enhance decision-making
in health ca…
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psnet.ahrq.gov/node/34695/psn-pdf
June 26, 2015 - Do house officers learn from their mistakes?
June 26, 2015
Wu AW, Folkman S, McPhee SJ, et al. Do house officers learn from their mistakes? JAMA.
1991;265(16):2089-94.
https://psnet.ahrq.gov/issue/do-house-officers-learn-their-mistakes
The authors report their 1991 survey on medical errors among internal medicine …
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psnet.ahrq.gov/node/837867/psn-pdf
August 17, 2022 - Distributed Cognition and the Role of Nurses in
Diagnostic Safety in the Emergency Department.
August 17, 2022
Manojlovich M, Krein SL, Kronick SL, et al. Rockville, MD: Agency for Healthcare Research and Quality;
August 2022. AHRQ Publication No. 22-0026-2-EF.
https://psnet.ahrq.gov/issue/distributed-cognition-an…
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psnet.ahrq.gov/node/73098/psn-pdf
September 07, 2021 - Achieving Excellence in the Diagnosis of Acute
Cardiovascular Events: Proceedings of a Workshop–in
Brief.
September 7, 2021
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2021.
https://psnet.ahrq.gov/issue/achieving-excellence-diagnosis-acute-cardiovascula…
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psnet.ahrq.gov/node/41820/psn-pdf
November 07, 2012 - Serious adverse events from accidental ingestion by
children of over-the-counter eye drops and nasal sprays.
November 7, 2012
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 25, 2012.
https://psnet.ahrq.gov/issue/serious-adverse-events-accidental-ingestion-children-over-counter-ey…
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psnet.ahrq.gov/node/38352/psn-pdf
June 14, 2011 - Developing a tool for assessing competency in root cause
analysis.
June 14, 2011
Gupta P, Varkey P. Developing a tool for assessing competency in root cause analysis. Jt Comm J Qual
Patient Saf. 2009;35(1):36-42.
https://psnet.ahrq.gov/issue/developing-tool-assessing-competency-root-cause-analysis
Root cause anal…
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psnet.ahrq.gov/node/43247/psn-pdf
August 02, 2015 - Characteristics of medical professional liability claims
against internists.
August 2, 2015
Mangalmurti SS, Harold JG, Parikh PD, et al. Characteristics of medical professional liability claims against
internists. JAMA Intern Med. 2014;174(6):993-5. doi:10.1001/jamainternmed.2014.1116.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/45370/psn-pdf
July 27, 2016 - Correct use of inhalers: help patients breathe easier.
July 27, 2016
ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.
https://psnet.ahrq.gov/issue/correct-use-inhalers-help-patients-breathe-easier
Patients and clinicians can make medication administration mistakes when new drug delivery mecha…
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psnet.ahrq.gov/node/44392/psn-pdf
August 12, 2015 - Petty, dangerous, disruptive doctors: watch out!
August 12, 2015
Crane ME. Medscape Business of Medicine. July 23, 2015.
https://psnet.ahrq.gov/issue/petty-dangerous-disruptive-doctors-watch-out
Disruptive behavior among clinicians is a recognized problem that can hinder teamwork and detract from a
culture of safe…
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psnet.ahrq.gov/node/40487/psn-pdf
June 01, 2011 - Developing and testing a tool to measure nurse/physician
communication in the intensive care unit.
June 1, 2011
Carbo AR, Tess AV, Roy CL, et al. Developing a High-Performance Team Training Framework for Internal
Medicine Residents. J Patient Saf. 2011;7(2). doi:10.1097/pts.0b013e31820dbe02.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/60331/psn-pdf
May 13, 2020 - How a Doctor Confronts Medical Error.
May 13, 2020
People’s Pharmacy. Show 1209. April 28, 2020.
https://psnet.ahrq.gov/issue/how-doctor-confronts-medical-error
Accidental harm to patients is a persistent challenge in health care. This interview features Dr. Danielle Ofri
who provides an overview of error in…
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psnet.ahrq.gov/node/60157/psn-pdf
March 25, 2020 - Conspicuous by its absence: diagnostic expert testing
under uncertainty.
March 25, 2020
Dai T, Singh S. Conspicuous by Its absence: diagnostic expert testing under uncertainty. Market Sci.
2020;39(3):540-563. doi:10.1287/mksc.2019.1201.
https://psnet.ahrq.gov/issue/conspicuous-its-absence-diagnostic-expert-testing…
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psnet.ahrq.gov/node/46997/psn-pdf
July 25, 2018 - Gross Negligence Manslaughter in Healthcare: The
Report of a Rapid Policy Review.
July 25, 2018
Williams N. Department of Health and Social Care. London, England: Crown Copyright; 2018.
https://psnet.ahrq.gov/issue/gross-negligence-manslaughter-healthcare-report-rapid-policy-review
Accountability for errors and or…
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psnet.ahrq.gov/node/44783/psn-pdf
January 13, 2016 - Black Box Thinking: Why Most People Never Learn From
Their Mistakes—But Some Do.
January 13, 2016
Syed M. New York, NY: Portfolio; 2015. ISBN: 9781591848226.
https://psnet.ahrq.gov/issue/black-box-thinking-why-most-people-never-learn-their-mistakes-some-do
Medicine and aviation are high-risk industries where failu…
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psnet.ahrq.gov/node/839330/psn-pdf
November 02, 2022 - Diagnosis: Reducing Errors and Improving Quality.
November 2, 2022
Schiff G. Chapter In: Loscalzo J, Fauci A, Kasper D, et al, eds. Harrison's Principles of Internal Medicine,
21e. New York, NY: McGraw Hill; 2022
https://psnet.ahrq.gov/issue/diagnosis-reducing-errors-and-improving-quality
The task of performing a …
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psnet.ahrq.gov/node/38361/psn-pdf
January 31, 2011 - IOM: shorten residents' work shifts to reduce fatigue,
improve patient safety.
January 31, 2011
Kuehn BM. IOM: Shorten residents' work shifts to reduce fatigue, improve patient safety. JAMA.
2009;301(3):259-61. doi:10.1001/jama.2008.940.
https://psnet.ahrq.gov/issue/iom-shorten-residents-work-shifts-reduce-fatigue…
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psnet.ahrq.gov/node/42734/psn-pdf
November 13, 2013 - Healthcare Inspection—Emergency Department Patient
Deaths: Memphis VAMC, Memphis, Tennessee.
November 13, 2013
Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report
No. 13-00505-348.
https://psnet.ahrq.gov/issue/healthcare-inspection-emergency-department-patient-deat…
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psnet.ahrq.gov/node/43020/psn-pdf
May 29, 2014 - Handoff practices in undergraduate medical education.
May 29, 2014
Liston BW, Tartaglia KM, Evans D, et al. Handoff practices in undergraduate medical education. J Gen
Intern Med. 2014;29(5):765-9. doi:10.1007/s11606-014-2806-0.
https://psnet.ahrq.gov/issue/handoff-practices-undergraduate-medical-education
This su…