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psnet.ahrq.gov/node/43629/psn-pdf
May 01, 2015 - Exposing physicians to reduced residency work hours
did not adversely affect patient outcomes after residency.
May 1, 2015
Jena AB, Schoemaker L, Bhattacharya J. Exposing physicians to reduced residency work hours did not
adversely affect patient outcomes after residency. Health Aff (Millwood). 2014;33(10):1832-40.…
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psnet.ahrq.gov/node/47210/psn-pdf
November 16, 2018 - A multi-stakeholder consensus-driven research agenda
for better understanding and supporting the emotional
impact of harmful events on patients and families.
November 16, 2018
Bell SK, Etchegaray J, Gaufberg E, et al. A Multi-Stakeholder Consensus-Driven Research Agenda for
Better Understanding and Supporting the …
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psnet.ahrq.gov/node/36342/psn-pdf
March 02, 2011 - Missed and delayed diagnoses in the ambulatory setting:
a study of closed malpractice claims.
March 2, 2011
Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study
of closed malpractice claims. Ann Intern Med. 2006;145(7):488-496.
https://psnet.ahrq.gov/issue/missed…
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psnet.ahrq.gov/node/43956/psn-pdf
January 01, 2016 - Monitoring the harm associated with use of
anticoagulants in pediatric populations through trigger-
based automated adverse-event detection.
June 21, 2015
Patregnani JT, Spaeder MC, Lemon V, et al. Monitoring the harm associated with use of anticoagulants in
pediatric populations through trigger-based automated ad…
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psnet.ahrq.gov/node/46493/psn-pdf
January 24, 2019 - Four states with robust prescription drug monitoring
programs reduced opioid dosages.
January 24, 2019
Haffajee RL, Mello MM, Zhang F, et al. Four States With Robust Prescription Drug Monitoring Programs
Reduced Opioid Dosages. Health Aff (Millwood). 2018;37(6):964-974. doi:10.1377/hlthaff.2017.1321.
https://psnet…
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psnet.ahrq.gov/node/47531/psn-pdf
June 19, 2019 - Patient Safety.
June 19, 2019
Health Aff (Millwood). 2018;37(11):1723-1908.
https://psnet.ahrq.gov/issue/patient-safety-14
The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This
special issue of Health Affairs, published 20 years after that report, highlights achie…
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psnet.ahrq.gov/node/45385/psn-pdf
January 03, 2017 - Viewing prevention of catheter-associated urinary tract
infection as a system: using systems engineering and
human factors engineering in a quality improvement
project in an academic medical center.
January 3, 2017
Rhee C, Phelps E, Meyer B, et al. Viewing Prevention of Catheter-Associated Urinary Tract Infection …
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psnet.ahrq.gov/node/39045/psn-pdf
April 04, 2011 - Risks of complications by attending physicians after
performing nighttime procedures.
April 4, 2011
Rothschild JM. Risks of Complications by Attending Physicians After Performing Nighttime Procedures.
JAMA. 2009;302(14):1565-1572. doi:10.1001/jama.2009.1423.
https://psnet.ahrq.gov/issue/risks-complications-attendi…
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psnet.ahrq.gov/node/46843/psn-pdf
June 21, 2018 - Electronic health record reviews to measure diagnostic
uncertainty in primary care.
June 21, 2018
Bhise V, Rajan SS, Sittig DF, et al. Electronic health record reviews to measure diagnostic uncertainty in
primary care. J Eval Clin Pract. 2018;24(3):545-551. doi:10.1111/jep.12912.
https://psnet.ahrq.gov/issue/elect…
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psnet.ahrq.gov/node/43323/psn-pdf
January 07, 2015 - Unrealized potential and residual consequences of
electronic prescribing on pharmacy workflow in the
outpatient pharmacy.
January 7, 2015
Nanji KC, Rothschild JM, Boehne JJ, et al. Unrealized potential and residual consequences of electronic
prescribing on pharmacy workflow in the outpatient pharmacy. J Am Med Inf…
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psnet.ahrq.gov/node/47104/psn-pdf
December 04, 2018 - Deriving a framework for a systems approach to agitated
patient care in the emergency department.
December 4, 2018
Wong AH, Ruppel H, Crispino LJ, et al. Deriving a Framework for a Systems Approach to Agitated Patient
Care in the Emergency Department. Jt Comm J Qual Patient Saf. 2018;44(5):279-292.
doi:10.1016/j.j…
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psnet.ahrq.gov/node/44709/psn-pdf
November 18, 2016 - Lost information during the handover of critically injured
trauma patients: a mixed-methods study.
November 18, 2016
Zakrison TL, Rosenbloom B, McFarlan A, et al. Lost information during the handover of critically injured
trauma patients: a mixed-methods study. BMJ Qual Saf. 2016;25(12):929-936. doi:10.1136/bmjqs-2…
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psnet.ahrq.gov/node/42968/psn-pdf
February 26, 2014 - From physician intent to the pharmacy label: prevalence
and description of discrepancies from a cross-sectional
evaluation of electronic prescriptions.
February 26, 2014
Cochran GL, Klepser DG, Morien M, et al. From physician intent to the pharmacy label: prevalence and
description of discrepancies from a cross-se…
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psnet.ahrq.gov/node/44522/psn-pdf
June 21, 2016 - Impact of an electronic alert notification system
embedded in radiologists' workflow on closed-loop
communication of critical results: a time series analysis.
June 21, 2016
Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in
radiologists' workflow on closed-loop com…
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psnet.ahrq.gov/node/47006/psn-pdf
October 13, 2018 - Assessment of the safety of discharging select patients
directly home from the intensive care unit: a multicenter
population-based cohort study.
October 13, 2018
Stelfox HT, Soo A, Niven DJ, et al. Assessment of the Safety of Discharging Select Patients Directly Home
From the Intensive Care Unit: A Multicenter Pop…
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psnet.ahrq.gov/node/44427/psn-pdf
October 13, 2015 - Problem list completeness in electronic health records: a
multi-site study and assessment of success factors.
October 13, 2015
Wright A, McCoy AB, Hickman T-TT, et al. Problem list completeness in electronic health records: A multi-
site study and assessment of success factors. Int J Med Inform. 2015;84(10):784-90.…
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psnet.ahrq.gov/node/39548/psn-pdf
November 02, 2010 - Patient-specific electronic decision support reduces
prescription of excessive doses.
November 2, 2010
Seidling HM, Schmitt SPW, Bruckner T, et al. Patient-specific electronic decision support reduces
prescription of excessive doses. Qual Saf Health Care. 2010;19(5):e15. doi:10.1136/qshc.2009.033175.
https://psnet…
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psnet.ahrq.gov/node/46491/psn-pdf
August 20, 2018 - A qualitative study of speaking out about patient safety
concerns in intensive care units.
August 20, 2018
Tarrant C, Leslie M, Bion J, et al. A qualitative study of speaking out about patient safety concerns in
intensive care units. Soc Sci Med. 2017;193:8-15. doi:10.1016/j.socscimed.2017.09.036.
https://psnet.ah…
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psnet.ahrq.gov/node/48030/psn-pdf
May 22, 2019 - A culture of openness is associated with lower mortality
rates among 137 English National Health Service acute
trusts.
May 22, 2019
Toffolutti V, Stuckler D. A Culture Of Openness Is Associated With Lower Mortality Rates Among 137
English National Health Service Acute Trusts. Health Aff (Millwood). 2019;38(5):844-…
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psnet.ahrq.gov/node/47372/psn-pdf
January 01, 2019 - Patient safety culture, health information technology
implementation, and medical office problems that could
lead to diagnostic error.
October 3, 2018
Campione JR, Mardon RE, McDonald KM. Patient Safety Culture, Health Information Technology
Implementation, and Medical Office Problems That Could Lead to Diagnostic…