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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/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…
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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/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/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/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/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/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/867380/psn-pdf
December 18, 2024 - Cognitive biases and artificial intelligence.
December 18, 2024
Wang J, Redelmeier DA. Cognitive biases and artificial intelligence. NEJM AI. 2024;1(12):AIcs2400639.
doi:10.1056/aics2400639.
https://psnet.ahrq.gov/issue/cognitive-biases-and-artificial-intelligence
Previous studies have raised concerns about cognit…
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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/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/43870/psn-pdf
January 28, 2015 - Peer review of medical practices: missed opportunities to
learn.
January 28, 2015
Kadar N. Peer review of medical practices: missed opportunities to learn. Am J Obstet Gynecol.
2014;211(6):596-601. doi:10.1016/j.ajog.2014.08.018.
https://psnet.ahrq.gov/issue/peer-review-medical-practices-missed-opportunities-learn…
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psnet.ahrq.gov/node/43038/psn-pdf
March 05, 2014 - Missed it.
March 5, 2014
Green MJ, Rieck R. Missed it. Ann Intern Med. 2013;158(5 Pt 1):357-61. doi:10.7326/0003-4819-158-5-
201303050-00013.
https://psnet.ahrq.gov/issue/missed-it-0
This piece uses a graphic novel format to depict a story of a diagnostic error that resulted in a patient’s
death. The attention-gr…
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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/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/72832/psn-pdf
March 10, 2021 - Communication and Transparency as a Means to
Strengthening Workplace Culture During COVID-19.
March 10, 2021
Nadkarni A, Levy-Carrick NC, Kroll DS, et al. Communication And Transparency As A Means To
Strengthening Workplace Culture During Covid-19. National Academy of Medicine; 2021.
doi:10.31478/202103a.
https:/…
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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/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/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/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…