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psnet.ahrq.gov/node/47857/psn-pdf
June 14, 2019 - The wicked problem of patient misidentification: how
could the technological revolution help address patient
safety?
June 14, 2019
Ferguson C, Hickman L, Macbean C, et al. The wicked problem of patient misidentification: How could the
technological revolution help address patient safety? J Clin Nurs. 2019;28(13-14…
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psnet.ahrq.gov/node/43779/psn-pdf
May 28, 2015 - Debriefing in the emergency department after clinical
events: a practical guide.
May 28, 2015
Kessler DO, Cheng A, Mullan PC. Debriefing in the Emergency Department After Clinical Events: A
Practical Guide. Ann Emerg Med. 2015;65(6):690-698. doi:10.1016/j.annemergmed.2014.10.019.
https://psnet.ahrq.gov/issue/debri…
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psnet.ahrq.gov/node/43698/psn-pdf
November 19, 2014 - Alcohol and drug testing of health professionals following
preventable adverse events: a bad idea.
November 19, 2014
Banja J. Alcohol and drug testing of health professionals following preventable adverse events: a bad idea.
Am J Bioeth. 2014;14(12):25-36. doi:10.1080/15265161.2014.964873.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/41414/psn-pdf
June 06, 2012 - Factors associated with reported preventable adverse
drug events: a retrospective, case-control study.
June 6, 2012
Beckett RD, Sheehan AH, Reddan JG. Factors associated with reported preventable adverse drug events:
a retrospective, case-control study. Ann Pharmacother. 2012;46(5):634-41. doi:10.1345/aph.1Q785.
h…
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psnet.ahrq.gov/node/73194/psn-pdf
April 28, 2021 - CLER Report of Findings 2021: Subprotocol for Operative
and Procedural Areas.
April 28, 2021
Kuhn CM, Newton RC, Damewood MD, et al, on behalf of the CLER Evaluation Committee, the CLER
Operative and Procedural Subprotocol National Advisory Group, and the CLER Program. Chicago, IL:
Accreditation Council for Gradua…
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psnet.ahrq.gov/node/43039/psn-pdf
August 24, 2016 - How Doctors Think.
August 24, 2016
Groopman J. Boston, MA: Houghton Mifflin; 2007. ISBN: 0618610030.
https://psnet.ahrq.gov/issue/how-doctors-think
In this book, the author presents several stories that illustrate the forces that shape physician decision-
making and may lead to diagnostic mistakes. Borrowing from …
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psnet.ahrq.gov/node/35977/psn-pdf
February 17, 2011 - Making patient safety the centerpiece of medical liability
reform.
February 17, 2011
Clinton HR, Obama B. Making Patient Safety the Centerpiece of Medical Liability Reform. New England
Journal of Medicine. 2006;354(21). doi:10.1056/nejmp068100.
https://psnet.ahrq.gov/issue/making-patient-safety-centerpiece-medical…
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psnet.ahrq.gov/node/848084/psn-pdf
April 26, 2023 - Cognitive bias and dissonance in surgical practice: a
narrative review.
April 26, 2023
Richburg CE, Dossett LA, Hughes TM. Cognitive bias and dissonance in surgical practice: a narrative
review. Surg Clin North Am. 2023;103(2):271-285. doi:10.1016/j.suc.2022.11.003.
https://psnet.ahrq.gov/issue/cognitive-bias-and-…
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psnet.ahrq.gov/node/41305/psn-pdf
April 18, 2012 - Is computer-assisted telephone triage safe? A
prospective surveillance study in walk-in patients with
non-life-threatening medical conditions.
April 18, 2012
Meer A, Gwerder T, Duembgen L, et al. Is computer-assisted telephone triage safe? A prospective
surveillance study in walk-in patients with non-life-threaten…
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psnet.ahrq.gov/node/37929/psn-pdf
February 18, 2011 - Impact of duty hour regulations on medical students'
education: views of key clinical faculty.
February 18, 2011
Reed DA, Levine RB, Miller RG, et al. Impact of duty hour regulations on medical students' education:
views of key clinical faculty. J Gen Intern Med. 2008;23(7):1084-9. doi:10.1007/s11606-008-0532-1.
h…
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psnet.ahrq.gov/node/48121/psn-pdf
August 21, 2019 - A randomized experimental study to assess the effect of
language on medical students' anxiety due to uncertainty.
August 21, 2019
Simpkin AL, Murphy Z, Armstrong KA. A randomized experimental study to assess the effect of language
on medical students' anxiety due to uncertainty. Diagnosis (Berl). 2019;6(3):269-276.…
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psnet.ahrq.gov/node/60943/psn-pdf
September 23, 2020 - Think twice: effects on diagnostic accuracy of returning
to the case to reflect upon the initial diagnosis.
September 23, 2020
Mamede S, Hautz WE, Berendonk C, et al. Think twice: effects on diagnostic accuracy of returning to the
case to reflect upon the initial diagnosis. Acad Med. 2020;95(8):1223-1229.
doi:10.1…
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psnet.ahrq.gov/node/46816/psn-pdf
March 21, 2018 - Results of an enhanced clinic handoff and resident
education on resident patient ownership and patient
safety.
March 21, 2018
Pincavage A, Dahlstrom M, Prochaska M, et al. Results of an enhanced clinic handoff and resident
education on resident patient ownership and patient safety. Acad Med. 2013;88(6):795-801.
d…
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psnet.ahrq.gov/node/47802/psn-pdf
March 04, 2019 - The path to diagnostic excellence includes feedback to
calibrate how clinicians think.
March 4, 2019
Meyer AND, Singh H. The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians
Think. JAMA. 2019;321(8):737-738. doi:10.1001/jama.2019.0113.
https://psnet.ahrq.gov/issue/path-diagnostic-excelle…
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psnet.ahrq.gov/node/73352/psn-pdf
June 02, 2021 - Improving diagnosis by feedback and deliberate practice:
one-on-one coaching for diagnostic maturation.
June 2, 2021
Sinha P, Pischel L, Sofair AN. Improving diagnosis by feedback and deliberate practice: one-on-one
coaching for diagnostic maturation. Diagnosis (Berl). 2021;8(2):157-160. doi:10.1515/dx-2020-0129.
…
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psnet.ahrq.gov/node/39568/psn-pdf
August 08, 2010 - The quality, safety and content of telephone and face-to-
face consultations: a comparative study.
August 8, 2010
McKinstry B, Hammersley V, Burton C, et al. The quality, safety and content of telephone and face-to-face
consultations: a comparative study. Qual Saf Health Care. 2010;19(4):298-303.
doi:10.1136/qshc.…
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psnet.ahrq.gov/node/36559/psn-pdf
July 14, 2010 - Description and evaluation of an interprofessional patient
safety course for health professions and related sciences
students.
July 14, 2010
Galt KA, Paschal KA, O'Brien RL, et al. Description and Evaluation of an Interprofessional Patient Safety
Course for Health Professions and Related Sciences Students. J Patie…
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psnet.ahrq.gov/node/45819/psn-pdf
March 15, 2017 - How doctors think: common diagnostic errors in clinical
judgment--lessons from an undiagnosed and rare disease
program.
March 15, 2017
Kliegman RM, Bordini BJ, Basel D, et al. How Doctors Think: Common Diagnostic Errors in Clinical
Judgment-Lessons from an Undiagnosed and Rare Disease Program. Pediatr Clin North A…
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psnet.ahrq.gov/node/43845/psn-pdf
September 26, 2016 - Disrupting diagnostic reasoning: do interruptions,
instructions, and experience affect the diagnostic
accuracy and response time of residents and emergency
physicians?
September 26, 2016
Monteiro SD, Sherbino JD, Ilgen JS, et al. Disrupting diagnostic reasoning: do interruptions, instructions,
and experience affe…
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psnet.ahrq.gov/node/73405/psn-pdf
June 16, 2021 - 2020 Eisenberg Award recipients announced by The Joint
Commission, National Quality Forum.
June 16, 2021
Oakbrook Terrace, IL: Joint Commission: June 8, 2021.
https://psnet.ahrq.gov/issue/2020-eisenberg-award-recipients-announced-joint-commission-national-
quality-forum
The Eisenberg Award honors individuals and …