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psnet.ahrq.gov/node/33934/psn-pdf
March 02, 2011 - A hospitalization from hell: a patient's perspective on
quality.
March 2, 2011
Cleary PD. A hospitalization from hell: a patient's perspective on quality. Ann Intern Med. 2003;138(1):33-
39.
https://psnet.ahrq.gov/issue/hospitalization-hell-patients-perspective-quality
The author shares the unique perspectives of…
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psnet.ahrq.gov/node/45581/psn-pdf
October 19, 2016 - Reducing diagnostic errors.
October 19, 2016
Gittlen S. HealthLeaders Media. October 1, 2016.
https://psnet.ahrq.gov/issue/reducing-diagnostic-errors-0
The recent recognition of diagnostic error as a blind spot in health care has driven the need to enhance
diagnosis. This news article reports how health systems, a…
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psnet.ahrq.gov/node/41685/psn-pdf
July 02, 2014 - Faculty member review and feedback using a sign-out
checklist: improving intern written sign-out.
July 2, 2014
Bump GM, Bost JE, Buranosky R, et al. Faculty member review and feedback using a sign-out checklist:
improving intern written sign-out. Acad Med. 2012;87(8):1125-31. doi:10.1097/ACM.0b013e31825d1215.
http…
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psnet.ahrq.gov/node/46322/psn-pdf
August 02, 2017 - Sophisticated digital aids could help determine what ails
you.
August 2, 2017
Maron DF. Scientific American. July 21, 2017.
https://psnet.ahrq.gov/issue/sophisticated-digital-aids-could-help-determine-what-ails-you
Clinical decision support systems are a key strategy to improve diagnostic accuracy. This magazine a…
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psnet.ahrq.gov/node/42660/psn-pdf
October 16, 2013 - Practice indicators of suboptimal care and avoidable
adverse events: a content analysis of a national qualifying
examination.
October 16, 2013
Bordage G, Meguerditchian A-N, Tamblyn R. Practice indicators of suboptimal care and avoidable adverse
events: a content analysis of a national qualifying examination. Acad…
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psnet.ahrq.gov/node/865345/psn-pdf
March 27, 2024 - The limits of clinician vigilance as an AI safety bulwark.
March 27, 2024
Adler-Milstein J, Redelmeier DA, Wachter RM. The limits of clinician vigilance as an AI safety bulwark.
JAMA. 2024;331(14):1173-1174. doi:10.1001/jama.2024.3620.
https://psnet.ahrq.gov/issue/limits-clinician-vigilance-ai-safety-bulwark
Human…
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psnet.ahrq.gov/node/44041/psn-pdf
April 01, 2015 - Potentially dangerous confusion between Bloxiverz
(neostigmine) injection and Vazculep (phenylephrine)
injection.
April 1, 2015
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American
Society of Health-System Pharmacists. March 23, 2015
https://psnet.ahrq.gov/issue/pot…
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psnet.ahrq.gov/node/35383/psn-pdf
January 02, 2017 - North Mississippi Medical Center: a focus on quality,
safety, and financial critical success factors.
January 2, 2017
Murphree J, Englert J, Koch K, et al. North Mississippi Medical Center: a focus on quality, safety, and
financial critical success factors. Jt Comm J Qual Patient Saf. 2005;31(10):545-53.
https://p…
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psnet.ahrq.gov/node/50867/psn-pdf
February 05, 2020 - Cognitive testing of older clinicians prior to
recredentialing.
February 5, 2020
Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA.
2020;323(2):179-180. doi:10.1001/jama.2019.18665.
https://psnet.ahrq.gov/issue/cognitive-testing-older-clinicians-prior-recredentialing
In an…
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psnet.ahrq.gov/node/38261/psn-pdf
December 03, 2008 - Systematic assessment of culture review as a tool to
assess errors in the clinical microbiology laboratory.
December 3, 2008
Goodyear N, Ulness BK, Prentice JL, et al. Systematic assessment of culture review as a tool to assess
errors in the clinical microbiology laboratory. Arch Pathol Lab Med. 2008;132(11):1792-5…
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psnet.ahrq.gov/node/43464/psn-pdf
August 27, 2014 - Using pharmacists to optimize patient outcomes and
costs in the ED.
August 27, 2014
Jacknin G, Nakamura T, Smally AJ, et al. Using pharmacists to optimize patient outcomes and costs in the
ED. Am J Emerg Med. 2014;32(6):673-7. doi:10.1016/j.ajem.2013.11.031.
https://psnet.ahrq.gov/issue/using-pharmacists-optimize-…
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psnet.ahrq.gov/node/46963/psn-pdf
April 18, 2018 - A Just Culture Guide.
April 18, 2018
NHS Improvement. London, UK: National Health Service; March 15, 2018.
https://psnet.ahrq.gov/issue/just-culture-guide
Although focusing on system failure has been highlighted as key to improving patient safety, individual
behaviors must also be recognized as contributors to ris…
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psnet.ahrq.gov/node/42872/psn-pdf
December 30, 2014 - Errors in after-hours phone consultations: a simulation
study.
December 30, 2014
Joffe E, Turley JP, Hwang KO, et al. Errors in after-hours phone consultations: a simulation study. BMJ
Qual Saf. 2014;23(5):398-405. doi:10.1136/bmjqs-2013-002243.
https://psnet.ahrq.gov/issue/errors-after-hours-phone-consultations-s…
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psnet.ahrq.gov/node/43759/psn-pdf
September 29, 2017 - Patients' expectations of the benefits and harms of
treatments, screening, and tests: a systematic review.
September 29, 2017
Hoffmann TC, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening, and
tests: a systematic review. JAMA Intern Med. 2015;175(2):274-286.
doi:10.1001/jamainte…
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psnet.ahrq.gov/node/47128/psn-pdf
October 13, 2018 - Matt's story: learning from heartbreak.
October 13, 2018
Miller K, Dastoli A. Matt's story: learning from heartbreak. Int J Qual Health Care. 2018;30(8):654-657.
doi:10.1093/intqhc/mzy076.
https://psnet.ahrq.gov/issue/matts-story-learning-heartbreak
Medical error affects the lives of patients, families, and member…
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psnet.ahrq.gov/node/73539/psn-pdf
July 28, 2021 - Developing critical thinking skills for delivering optimal
care
July 28, 2021
Scott IA, Hubbard RE, Crock C, et al. Developing critical thinking skills for delivering optimal care. Intern
Med J. 2021;51(4):488-493. doi:10.1111/imj.15272.
https://psnet.ahrq.gov/issue/developing-critical-thinking-skills-delivering-o…
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psnet.ahrq.gov/node/41394/psn-pdf
December 29, 2014 - An adverse event screening tool based on routinely
collected hospital-acquired diagnoses.
December 29, 2014
Brand CA, Tropea J, Gorelik A, et al. An adverse event screening tool based on routinely collected
hospital-acquired diagnoses. Int J Qual Health Care. 2012;24(3):266-78. doi:10.1093/intqhc/mzs007.
https://p…
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psnet.ahrq.gov/node/46927/psn-pdf
April 04, 2018 - Clinician Well-Being Knowledge Hub.
April 4, 2018
Washington, DC: National Academy of Medicine.
https://psnet.ahrq.gov/issue/clinician-well-being-knowledge-hub
Clinician burnout can detract from individual wellness, patient safety, and organizational health. This
website serves as a companion to a collaborative ef…
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psnet.ahrq.gov/node/47620/psn-pdf
January 16, 2019 - Factors underlying suboptimal diagnostic performance in
physicians under time pressure.
January 16, 2019
ALQahtani DA, Rotgans JI, Mamede S, et al. Factors underlying suboptimal diagnostic performance in
physicians under time pressure. Med Educ. 2018;52(12):1288-1298. doi:10.1111/medu.13686.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45647/psn-pdf
February 22, 2017 - Bias in the ER. Doctors suffer from the same cognitive
distortions as the rest of us.
February 22, 2017
Lewis M. Nautilus. February 9, 2017.
https://psnet.ahrq.gov/issue/bias-er-doctors-suffer-same-cognitive-distortions-rest-us
Physicians' decision-making can be diminished when they are tired, distracted, or too n…