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psnet.ahrq.gov/node/43760/psn-pdf
March 20, 2015 - Pending studies at hospital discharge: a pre-post analysis
of an electronic medical record tool to improve
communication at hospital discharge.
March 20, 2015
Kantor MA, Evans KH, Shieh L. Pending studies at hospital discharge: a pre-post analysis of an electronic
medical record tool to improve communication at ho…
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psnet.ahrq.gov/node/42800/psn-pdf
July 03, 2016 - Why do doctors make mistakes? A study of the role of
salient distracting clinical features.
July 3, 2016
Mamede S, Van Gog T, Van den Berge K, et al. Why do doctors make mistakes? A study of the role of
salient distracting clinical features. Acad Med. 2014;89(1):114-20. doi:10.1097/ACM.0000000000000077.
https://ps…
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psnet.ahrq.gov/node/44045/psn-pdf
December 04, 2015 - Residents' reluctance to challenge negative hierarchy in
the operating room: a qualitative study.
December 4, 2015
Bould D, Sutherland S, Sydor DT, et al. Residents' reluctance to challenge negative hierarchy in the
operating room: a qualitative study. Can J Anaesth. 2015;62(6):576-86. doi:10.1007/s12630-015-0364-5…
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psnet.ahrq.gov/node/838930/psn-pdf
October 26, 2022 - Artificial Intelligence in Health Care: Benefits and
Challenges of Machine Learning Technologies for Medical
Diagnostics.
October 26, 2022
Washington DC: United States Government Accountability Office and National Academy of
Medicine; September 2022. Report no. GAO-22-104629.
https://psnet.ahrq.gov/issue/ar…
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psnet.ahrq.gov/node/45878/psn-pdf
September 20, 2017 - Development of a trigger tool to identify adverse events
and harm in emergency medical services.
September 20, 2017
Howard IL, Bowen JM, Shaikh LAHA, et al. Development of a trigger tool to identify adverse events and
harm in Emergency Medical Services. Emerg Med J. 2017;34(6):391-397. doi:10.1136/emermed-2016-
20…
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psnet.ahrq.gov/node/34662/psn-pdf
December 24, 2008 - User's manual for the IOM's 'Quality Chasm' report.
December 24, 2008
Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood). 2002;21(3):80-90.
https://psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report
Fifteen months after releasing its report on patient safety (To Err Is …
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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/847729/psn-pdf
April 19, 2023 - STAMP: a 5-year project to reduce paediatric prescribing
errors.
April 19, 2023
Trivedi A, Ajitsaria R, Bate T. STAMP: a 5-year project to reduce paediatric prescribing errors. Arch Dis
Child Educ Pract Ed. 2022;108(2):115-119. doi:10.1136/archdischild-2021-323192.
https://psnet.ahrq.gov/issue/stamp-5-year-project…
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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…