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psnet.ahrq.gov/issue/designing-human-centered-ai-prevent-medication-dispensing-errors-focus-group-study
August 31, 2022 - Study
Designing human-centered AI to prevent medication dispensing errors: focus group study with pharmacists.
Citation Text:
Zheng Y, Rowell B, Chen Q, et al. Designing human-centered AI to prevent medication dispensing errors: focus group study with pharmacists. JMIR Form Res. 2023;7:e…
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psnet.ahrq.gov/issue/evaluation-electronic-health-record-implementation-pharmacist-interventions-related-oral
January 25, 2023 - Study
Evaluation of electronic health record implementation on pharmacist interventions related to oral chemotherapy management.
Citation Text:
Finn A, Bondarenka C, Edwards K, et al. Evaluation of electronic health record implementation on pharmacist interventions related to oral chemot…
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psnet.ahrq.gov/issue/contributors-diagnostic-error-or-delay-acute-care-setting-survey-clinical-stakeholders
May 26, 2021 - Study
Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders.
Citation Text:
Redmond S, Barwise A, Zornes S, et al. Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders. Health Serv Insights…
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psnet.ahrq.gov/issue/interventions-targeted-reducing-diagnostic-error-systematic-review
March 10, 2021 - Review
Interventions targeted at reducing diagnostic error: systematic review.
Citation Text:
Dave N, Bui S, Morgan C, et al. Interventions targeted at reducing diagnostic error: systematic review. BMJ Qual Saf. 2022;31(4):297-307. doi:10.1136/bmjqs-2020-012704.
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psnet.ahrq.gov/issue/ahrq-report-diagnostic-errors-emergency-department-wrong-answer-wrong-question
September 23, 2020 - Commentary
The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong answer to the wrong question.
Citation Text:
Kelen GD, Kaji AH, Schreyer KE, et al. The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong answer to the wrong question. Ann Emerg M…
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psnet.ahrq.gov/issue/improving-quality-insulin-prescribing-people-diabetes-being-discharged-hospital
November 16, 2022 - Journal Article
Improving the quality of insulin prescribing for people with diabetes being discharged from hospital
Citation Text:
Bain A, Silcock J, Kavanagh S, et al. Improving the quality of insulin prescribing for people with diabetes being discharged from hospital. BMJ Open Qual. 2…
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psnet.ahrq.gov/issue/quantification-and-classification-errors-associated-hand-repackaging-medications-long-term
April 21, 2021 - Study
Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany.
Citation Text:
Gerber A, Kohaupt I, Lauterbach KW, et al. Quantification and classification of errors associated with hand-repackaging of medicat…
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psnet.ahrq.gov/issue/medication-errors-among-adults-and-children-cancer-outpatient-setting
January 16, 2010 - Study
Medication errors among adults and children with cancer in the outpatient setting.
Citation Text:
Walsh KE, Dodd KS, Seetharaman K, et al. Medication errors among adults and children with cancer in the outpatient setting. J Clin Oncol. 2009;27(6):891-6. doi:10.1200/JCO.2008.18.60…
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psnet.ahrq.gov/issue/performance-variability-perioperative-sentinel-events-report-nationwide-data-set
November 04, 2020 - Study
Performance variability in perioperative sentinel events: report on a nationwide data set.
Citation Text:
Reijmerink IM, Bos K, Leistikow IP, et al. Performance variability in perioperative sentinel events: report on a nationwide data set. Br J Surg. 2022;109(7):573-575. doi:10.109…
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psnet.ahrq.gov/issue/inpatient-suicide-and-suicide-attempts-veterans-affairs-hospitals
January 02, 2017 - Study
Inpatient suicide and suicide attempts in Veterans Affairs hospitals.
Citation Text:
Mills PD, DeRosier JM, Ballot BA, et al. Inpatient suicide and suicide attempts in Veterans Affairs hospitals. Jt Comm J Qual Patient Saf. 2008;34(8):482-488.
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psnet.ahrq.gov/issue/improving-medication-error-reporting-hospice-care
June 22, 2022 - Study
Improving medication error reporting in hospice care.
Citation Text:
Boyer R, McPherson ML, Deshpande G, et al. Improving medication error reporting in hospice care. Am J Hosp Palliat Care. 2009;26(5):361-7. doi:10.1177/1049909109335145.
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psnet.ahrq.gov/issue/system-issues-leading-found-floor-incidents-multi-incident-analysis
August 04, 2021 - Study
System issues leading to "found-on-floor" incidents: a multi-incident analysis.
Citation Text:
Shaw J, Bastawrous M, Burns S, et al. System Issues Leading to “Found-on-Floor” Incidents: A Multi-Incident Analysis. J Patient Saf. 2021;17(1):30-35. doi:10.1097/pts.0000000000000294.
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psnet.ahrq.gov/issue/remote-patient-monitoring-during-covid-19-unexpected-patient-safety-benefit
July 20, 2022 - Commentary
Remote patient monitoring during COVID-19: an unexpected patient safety benefit.
Citation Text:
Pronovost PJ, Cole MD, Hughes RM. Remote patient monitoring during COVID-19: an unexpected patient safety benefit. JAMA. 2022;327(12):1125-1126. doi:10.1001/jama.2022.2040.
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psnet.ahrq.gov/issue/learning-mistakes-easier-said-done-group-and-organizational-influences-detection-and
September 25, 2024 - Study
Classic
Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error.
Citation Text:
Edmondson AC. Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences o…
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psnet.ahrq.gov/issue/creating-safer-health-care-system-finding-constraint
February 24, 2011 - Commentary
Creating a safer health care system: finding the constraint.
Citation Text:
Pauker SG, Zane EM, Salem D. Creating a safer health care system: finding the constraint. JAMA. 2005;294(22):2906-8.
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psnet.ahrq.gov/issue/association-clinical-specialty-symptoms-burnout-and-career-choice-regret-among-us-resident
December 21, 2018 - Study
Classic
Association of clinical specialty with symptoms of burnout and career choice regret among US resident physicians.
Citation Text:
Dyrbye LN, Burke SE, Hardeman RR, et al. Association of Clinical Specialty With Symptoms of Burnout and Career Choice R…
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psnet.ahrq.gov/issue/triggers-contributing-health-care-clinicians-disruptive-behaviors
June 24, 2020 - Study
Triggers contributing to health care clinicians' disruptive behaviors.
Citation Text:
Bae S-H, Dang D, Karlowicz KA, et al. Triggers contributing to health care clinicians' disruptive behaviors. J Patient Saf. 2020;16(3):e148-e155. doi:10.1097/pts.0000000000000288.
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psnet.ahrq.gov/issue/text-mining-approach-categorize-patient-safety-event-reports-medication-error-type
December 07, 2022 - Study
A text mining approach to categorize patient safety event reports by medication error type.
Citation Text:
Boxley C, Fujimoto M, Ratwani RM, et al. A text mining approach to categorize patient safety event reports by medication error type. Sci Rep. 2023;13(1):18354. doi:10.1038/s41…
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psnet.ahrq.gov/issue/development-preliminary-patient-safety-classification-system-generative-ai
December 21, 2022 - Study
Development of a preliminary patient safety classification system for generative AI.
Citation Text:
Hose B-Z, Handley JL, Biro J, et al. Development of a preliminary patient safety classification system for generative AI. BMJ Qual Saf. 2025;34(2):130-132. doi:10.1136/bmjqs-2024-017…
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - Learning Health Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
Despite an observable decrease in adverse events in health care over time, rat…