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psnet.ahrq.gov/issue/analysis-near-misses-identified-anesthesia-providers-intensive-care-unit
August 17, 2017 - Study
An analysis of near misses identified by anesthesia providers in the intensive care unit.
Citation Text:
Lipshutz AKM, Caldwell JE, Robinowitz DL, et al. An analysis of near misses identified by anesthesia providers in the intensive care unit. BMC Anesthesiol. 2015;15:93. doi:10.11…
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psnet.ahrq.gov/issue/ethical-dilemma-missed-melanoma-what-tell-patient-and-other-providers
March 17, 2021 - Commentary
Ethical dilemma in missed melanoma: what to tell the patient and other providers.
Citation Text:
Vangipuram R, Horner ME, Menter A. Ethical dilemma in missed melanoma: What to tell the patient and other providers. J Am Acad Dermatol. 2017;76(2):365-367. doi:10.1016/j.jaad.2016…
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psnet.ahrq.gov/issue/program-provide-clinicians-feedback-their-diagnostic-performance-learning-health-system
October 12, 2022 - Study
A program to provide clinicians with feedback on their diagnostic performance in a learning health system.
Citation Text:
Meyer AND, Upadhyay DK, Collins CA, et al. A program to provide clinicians with feedback on their diagnostic performance in a learning health system. Jt Comm J …
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psnet.ahrq.gov/node/33586/psn-pdf
December 15, 2024 - Alert Fatigue
December 15, 2024
Alert Fatigue. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/alert-fatigue
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Bac…
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psnet.ahrq.gov/node/46691/psn-pdf
December 06, 2017 - Improved Policies and Oversight Needed for Reviewing
and Reporting Providers for Quality and Safety Concerns.
December 6, 2017
Washington, DC: United States Government Accountability Office; November 2017. Publication GAO-18-
63.
https://psnet.ahrq.gov/issue/improved-policies-and-oversight-needed-reviewing-and-rep…
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psnet.ahrq.gov/node/43842/psn-pdf
January 28, 2015 - Should health care providers be forced to apologise after
things go wrong?
January 28, 2015
McLennan S, Walker S, Rich LE. Should health care providers be forced to apologise after things go
wrong? J Bioeth Inq. 2014;11(4):431-5. doi:10.1007/s11673-014-9571-y.
https://psnet.ahrq.gov/issue/should-health-care-provid…
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psnet.ahrq.gov/node/46741/psn-pdf
June 07, 2018 - Suffering in silence: medical error and its impact on
health care providers.
June 7, 2018
Robertson JJ, Long B. Suffering in Silence: Medical Error and its Impact on Health Care Providers. J
Emerg Med. 2018;54(4). doi:10.1016/j.jemermed.2017.12.001.
https://psnet.ahrq.gov/issue/suffering-silence-medical-error-and-…
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psnet.ahrq.gov/node/37273/psn-pdf
May 11, 2014 - Impact of computerized prescriber order entry (CPOE) on
clinical pharmacy practice: a hypothesis-generating
study.
May 11, 2014
Lai JS, Yokoyama G, Louie C, et al. Impact of Computerized Prescriber Order Entry (CPOE) on Clinical
Pharmacy Practice: A Hypothesis-Generating Study. Hosp Pharm. 2010;42(10):931-938.
do…
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psnet.ahrq.gov/node/838927/psn-pdf
October 26, 2022 - Survey results from pharmacists provide support to
enhance the organizational response to codes.
October 26, 2022
ISMP Medication Safety Alert! Acute care edition. October 6, 2022;27(20):1-5.
https://psnet.ahrq.gov/issue/survey-results-pharmacists-provide-support-enhance-organizational-response-
codes
Patient res…
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psnet.ahrq.gov/node/865874/psn-pdf
May 15, 2024 - Perceptions of U.S. and U.K. incident reporting systems:
a scoping review.
May 15, 2024
Gampetro PJ, Nickum A, Schultz CM. Perceptions of U.S. and U.K. incident reporting systems: a scoping
review. J Patient Saf. 2024;20(5):360-365. doi:10.1097/pts.0000000000001231.
https://psnet.ahrq.gov/issue/perceptions-us-and-…
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psnet.ahrq.gov/node/865681/psn-pdf
April 24, 2024 - DOD Should Improve Its Process for Clinical Adverse
Actions against Providers.
April 24, 2024
Washington, DC: United States Government Accounting Office; April 11, 2024. Publication GAO-24-
106107.
https://psnet.ahrq.gov/issue/dod-should-improve-its-process-clinical-adverse-actions-against-providers
Health care o…
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psnet.ahrq.gov/node/41393/psn-pdf
June 06, 2012 - Prescribers' interactions with medication alerts at the
point of prescribing: a multi-method, in situ investigation
of the human–computer interaction.
June 6, 2012
Russ AL, Zillich AJ, McManus S, et al. Prescribers' interactions with medication alerts at the point of
prescribing: A multi-method, in situ investigat…
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psnet.ahrq.gov/node/42996/psn-pdf
March 19, 2014 - The "physician-led chart audit": engaging providers in
fortifying a culture of safety.
March 19, 2014
Gitkind MJ, Perla RJ, Manno M, et al. The "physician-led chart audit: " engaging providers in fortifying a
culture of safety. J Patient Saf. 2014;10(1):72-9. doi:10.1097/PTS.0000000000000057.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/39773/psn-pdf
August 18, 2010 - Preventing potentially inappropriate medication use in
hospitalized older patients with a computerized provider
order entry warning system.
August 18, 2010
Mattison MLP, Afonso KA, Ngo LH, et al. Preventing potentially inappropriate medication use in
hospitalized older patients with a computerized provider order e…
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psnet.ahrq.gov/node/72486/psn-pdf
November 18, 2020 - ISMP Survey provides insights into preparation and
admixture practices OUTSIDE the pharmacy.
November 18, 2020
ISMP Medication Safety Alert! Acute care edition. November 5, 2020;25(22)1-5.
https://psnet.ahrq.gov/issue/ismp-survey-provides-insights-preparation-and-admixture-practices-outside-
pharmacy
Mistakes in …
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psnet.ahrq.gov/issue/why-patient-summaries-electronic-health-records-do-not-provide-cognitive-support-necessary
January 18, 2013 - Study
Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.
Citation Text:
Staggers N, Clark L, Blaz JW, et al. Why patient summaries in electronic…
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psnet.ahrq.gov/issue/does-computerized-provider-order-entry-reduce-prescribing-errors-hospital-inpatients
February 15, 2012 - Review
Does computerized provider order entry reduce prescribing errors for hospital inpatients? A systematic review.
Citation Text:
Reckmann MH, Westbrook JI, Koh Y, et al. Does computerized provider order entry reduce prescribing errors for hospital inpatients? A systematic review. J…
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psnet.ahrq.gov/issue/strengthening-open-disclosure-maternity-services-english-nhs-discern-realist-evaluation-study
April 12, 2023 - Study
Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study.
Citation Text:
Adams MA, Bevan C, Booker M, et al. Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study. Health Soc …
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psnet.ahrq.gov/issue/are-we-heeding-warning-signs-examining-providers-overrides-computerized-drug-drug-interaction
September 01, 2016 - Study
Are we heeding the warning signs? Examining providers' overrides of computerized drug–drug interaction alerts in primary care.
Citation Text:
Slight SP, Seger DL, Nanji KC, et al. Are we heeding the warning signs? Examining providers' overrides of computerized drug-drug interaction…
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psnet.ahrq.gov/issue/inviting-patients-identify-diagnostic-concerns-through-structured-evaluation-their-online
March 03, 2021 - Study
Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes.
Citation Text:
Giardina TD, Choi DT, Upadhyay DK, et al. Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes. J Am Me…