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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
August 01, 2015 - PowerPoint Presentation
Spotlight
Privacy or Safety?
1
This presentation is based on the July/August 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John D. Halamka, MD, MS, Beth Israel Deaconess Medical Center; and Deven McGraw, JD, MPH, LLM…
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psnet.ahrq.gov/node/44184/psn-pdf
June 24, 2015 - Electronic prescription writing errors in the pediatric
emergency department.
June 24, 2015
Nelson CE, Selbst SM. Electronic prescription writing errors in the pediatric emergency department. Pediatr
Emerg Care. 2015;31(5):368-72. doi:10.1097/PEC.0000000000000428.
https://psnet.ahrq.gov/issue/electronic-prescripti…
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psnet.ahrq.gov/node/35282/psn-pdf
May 27, 2011 - Comprehensive analysis of a medication dosing error
related to CPOE.
May 27, 2011
Horsky J, Kuperman GJ, Patel VL. Comprehensive Analysis of a Medication Dosing Error Related to
CPOE: Table 1. J Am Med Info Assoc. 2005;12(4). doi:10.1197/jamia.m1740.
https://psnet.ahrq.gov/issue/comprehensive-analysis-medication-d…
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psnet.ahrq.gov/node/38889/psn-pdf
April 01, 2010 - Anatomy of a failure: a sociotechnical evaluation of a
laboratory physician order entry system implementation.
April 1, 2010
Peute LW, Aarts J, Bakker PJM, et al. Anatomy of a failure: a sociotechnical evaluation of a laboratory
physician order entry system implementation. Int J Med Inform. 2010;79(4):e58-70.
doi:…
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psnet.ahrq.gov/node/46974/psn-pdf
April 04, 2018 - From guideline to order set to patient harm.
April 4, 2018
Shah SD, Cifu AS. From Guideline to Order Set to Patient Harm. JAMA. 2018;319(12):1207-1208.
doi:10.1001/jama.2018.1666.
https://psnet.ahrq.gov/issue/guideline-order-set-patient-harm
This editorial discusses how adverse events can occur if standardized ord…
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psnet.ahrq.gov/node/837057/psn-pdf
May 11, 2022 - Presenting complaint: use of language that disempowers
patients.
May 11, 2022
doi:10.1136/bmj-2021-066720.
https://psnet.ahrq.gov/issue/presenting-complaint-use-language-disempowers-patients
As more patients are gaining access to their electronic health records, including clinician notes, the
language clinicians …
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psnet.ahrq.gov/node/40603/psn-pdf
December 31, 2014 - ICU nurses' acceptance of electronic health records.
December 31, 2014
Carayon P, Cartmill R, Blosky MA, et al. ICU nurses' acceptance of electronic health records. J Am Med
Inform Assoc. 2011;18(6):812-9. doi:10.1136/amiajnl-2010-000018.
https://psnet.ahrq.gov/issue/icu-nurses-acceptance-electronic-health-records
…
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psnet.ahrq.gov/node/47803/psn-pdf
October 07, 2021 - Letter to Health Care Providers: Safe Use of Surgical
Staplers and Staples.
October 7, 2021
US Food and Drug Administration. October 7, 2021.
https://psnet.ahrq.gov/issue/letter-health-care-providers-safe-use-surgical-staplers-and-staples
Errors of commission during complex procedures can contribute to patient har…
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psnet.ahrq.gov/node/73256/psn-pdf
May 12, 2021 - Addiction treatment providers in Pa. face little state
scrutiny despite harm to clients.
May 12, 2021
Pattani A, Mahon E. Kaiser Health News. April 30, 2021.
https://psnet.ahrq.gov/issue/addiction-treatment-providers-pa-face-little-state-scrutiny-despite-harm-clients
Systemic oversight weaknesses and lack of…
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psnet.ahrq.gov/node/39619/psn-pdf
September 26, 2010 - Devastatingly human: an analysis of registered nurses'
medication error accounts.
September 26, 2010
Treiber LA, Jones JH. Devastatingly human: an analysis of registered nurses' medication error accounts.
Qual Health Res. 2010;20(10):1327-42. doi:10.1177/1049732310372228.
https://psnet.ahrq.gov/issue/devastatingly…
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psnet.ahrq.gov/node/74261/psn-pdf
January 19, 2022 - Implicit bias in healthcare professionals: a systematic
review.
January 19, 2022
FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics.
2017;18(1):19. doi:10.1186/s12910-017-0179-8.
https://psnet.ahrq.gov/issue/implicit-bias-healthcare-professionals-systematic-review…
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psnet.ahrq.gov/node/855103/psn-pdf
November 08, 2023 - Adverse Events.
November 8, 2023
United States Office of the Inspector General: 2010-2023.
https://psnet.ahrq.gov/issue/adverse-events-0
Large-scale data analysis provides insights to generate evidence-based improvement action. This
collection of reports provides access to investigations of the impact of heal…
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psnet.ahrq.gov/node/35749/psn-pdf
May 09, 2014 - Chemotherapy dose limits set by users of a computer
order entry system.
May 9, 2014
DuBeshter B; Griggs J; Angel C; Loughner J.
https://psnet.ahrq.gov/issue/chemotherapy-dose-limits-set-users-computer-order-entry-system
To avoid excessive dosing of chemotherapeutic agents, standardized dose limits must be agreed u…
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psnet.ahrq.gov/node/40478/psn-pdf
June 13, 2011 - Evaluating the medication process in the context of CPOE
use: the significance of working around the system.
June 13, 2011
Niazkhani Z, Pirnejad H, van der Sijs H, et al. Evaluating the medication process in the context of CPOE
use: the significance of working around the system. Int J Med Inform. 2011;80(7):490-506…
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psnet.ahrq.gov/node/33934/psn-pdf
March 02, 2011 - A hospitalization from hell: a patient's perspective on
quality.
March 2, 2011
Cleary PD. A hospitalization from hell: a patient's perspective on quality. Ann Intern Med. 2003;138(1):33-
39.
https://psnet.ahrq.gov/issue/hospitalization-hell-patients-perspective-quality
The author shares the unique perspectives of…
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psnet.ahrq.gov/node/38540/psn-pdf
April 08, 2009 - Drug-related problems in medical wards with a
computerized physician order entry system.
April 8, 2009
Bedouch P, Allenet B, Grass A, et al. Drug-related problems in medical wards with a computerized
physician order entry system. J Clin Pharm Ther. 2009;34(2):187-95. doi:10.1111/j.1365-
2710.2008.00990.x.
https:/…
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psnet.ahrq.gov/node/44838/psn-pdf
February 10, 2016 - ADVERSE drug events: incidence and risk reduction
across the care continuum.
February 10, 2016
Wanderer JP, Rathmell JP. ADVERSE Drug Events: Incidence & risk reduction across the care continuum.
Anesthesiology. 2016;124(1):A23. doi:10.1097/01.anes.0000473722.20007.03.
https://psnet.ahrq.gov/issue/adverse-drug-eve…
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psnet.ahrq.gov/node/35786/psn-pdf
May 07, 2007 - When Things Go Wrong: Responding to Adverse Events.
May 7, 2007
Boston, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
https://psnet.ahrq.gov/issue/when-things-go-wrong-responding-adverse-events
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk manage…
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psnet.ahrq.gov/node/34750/psn-pdf
May 21, 2019 - The Basics of FMEA. 2nd ed.
May 21, 2019
McDermott RE, Mikulak RJ, Beauregard MR. New York, NY: CRC Press; 2009. ISBN: 9781563273773.
https://psnet.ahrq.gov/issue/basics-fmea-2nd-edition
The authors provide a handbook that serves as the core tool for understanding and implementing the
failure mode and effect analy…
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psnet.ahrq.gov/node/49707/psn-pdf
April 01, 2014 - CYP450 Drugs: Expect the Unexpected
April 1, 2014
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
The Case
A 42-year-old man with acquired immunodeficiency syndrome (AIDS) (CD4 count 198), hip dystocia, and
generalized anxiety …