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psnet.ahrq.gov/node/74182/psn-pdf
December 15, 2021 - Honesty and transparency, indispensable to the clinical
mission--Parts I-III.
December 15, 2021
Brenner MJ, Boothman RC, Rushton CH, et al. Honesty and Transparency, Indispensable to the Clinical
Mission—Parts I - III. Otolaryngol Clin North Am. 2021;55(1):43-103. doi:10.1016/j.otc.2021.07.016.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/35639/psn-pdf
May 27, 2011 - Clinical application of a computerized system for
physician order entry with clinical decision support to
prevent adverse drug events in long-term care.
May 27, 2011
Rochon P, Field T, Bates DW, et al. Clinical application of a computerized system for physician order entry
with clinical decision support to prevent…
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psnet.ahrq.gov/node/38799/psn-pdf
September 29, 2009 - Work-arounds and artifacts during transition to a
computer physician order entry: what they are and what
they mean.
September 29, 2009
Schoville RR. Work-arounds and artifacts during transition to a computer physician order entry: what they
are and what they mean. J Nurs Care Qual. 2009;24(4):316-324. doi:10.1097/…
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psnet.ahrq.gov/node/41954/psn-pdf
November 26, 2014 - Decoding laboratory test names: a major challenge to
appropriate patient care.
November 26, 2014
Passiment E, Meisel JL, Fontanesi J, et al. Decoding laboratory test names: a major challenge to
appropriate patient care. J Gen Intern Med. 2013;28(3):453-8. doi:10.1007/s11606-012-2253-8.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/852451/psn-pdf
August 16, 2023 - The impact of transition to a digital hospital on
medication errors (TIME study).
August 16, 2023
Engstrom T, McCourt E, Canning M, et al. The impact of transition to a digital hospital on medication errors
(TIME study). NPJ Digit Med. 2023;6(1):133. doi:10.1038/s41746-023-00877-w.
https://psnet.ahrq.gov/issue/imp…
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psnet.ahrq.gov/node/35028/psn-pdf
May 27, 2011 - Medication errors and adverse drug events in pediatric
inpatients.
May 27, 2011
Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric
inpatients. JAMA. 2001;285(16):2114-20.
https://psnet.ahrq.gov/issue/medication-errors-and-adverse-drug-events-pediatric-inpatients
This p…
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psnet.ahrq.gov/node/42989/psn-pdf
May 28, 2014 - Interactive questioning in critical care during handovers:
a transcript analysis of communication behaviours by
physicians, nurses and nurse practitioners.
May 28, 2014
Rayo MF, Mount-Campbell AF, O'Brien JM, et al. Interactive questioning in critical care during handovers: a
transcript analysis of communication b…
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psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
October 01, 2013 - New Patient Mistakenly Checked in as Another
Citation Text:
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar B…
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - SPOTLIGHT CASE
The Wet Read
Citation Text:
Arenson RL. The Wet Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/web-mm/time-death
January 03, 2017 - Time of Death?
Citation Text:
Taekman JM, Wright MC. Time of Death?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/node/49491/psn-pdf
September 01, 2005 - Time of Death?
September 1, 2005
Taekman JM, Wright MC. Time of Death? PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/time-death
The Case
An 80-year-old woman with multiple illnesses, including chronic obstructive pulmonary disease (COPD),
was found pulseless and cyanotic in her hospital bed. A code was ca…
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psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
June 01, 2004 - SPOTLIGHT CASE
Duty to Disclose Someone Else's Error?
Citation Text:
Gallagher TH. Duty to Disclose Someone Else's Error?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
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psnet.ahrq.gov/node/837029/psn-pdf
May 04, 2022 - Identifying patients whose symptoms are
underrecognized during treatment with breast
radiotherapy.
May 4, 2022
doi:10.1001/jamaoncol.2022.0114.
https://psnet.ahrq.gov/issue/identifying-patients-whose-symptoms-are-underrecognized-during-treatment-
breast-radiotherapy
Concordance of patient-reported symptoms and p…
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psnet.ahrq.gov/node/865595/psn-pdf
January 01, 2024 - Black women's maternal health: insights from community
based participatory research in Newark, New Jersey.
June 29, 2023
Kantor LM, Cruz N, Adams C, et al. Black women's maternal health: insights from community based
participatory research in Newark, New Jersey. Behav Med. 2024;50(3):224-231.
doi:10.1080/08964289.…
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psnet.ahrq.gov/node/47754/psn-pdf
April 17, 2019 - FDA identifies harm reported from sudden
discontinuation of opioid pain medicines and requires
label changes to guide prescribers on gradual,
individualized tapering.
April 17, 2019
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
https://psnet.ahrq.gov/issue/fda-identifies-harm-reported-sudden-…
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psnet.ahrq.gov/node/44075/psn-pdf
July 16, 2015 - Physicians failed to write flawless prescriptions when
computerized physician order entry system crashed.
July 16, 2015
Hsu C-C, Chou C-L, Chen T-J, et al. Physicians Failed to Write Flawless Prescriptions When Computerized
Physician Order Entry System Crashed. Clin Ther. 2015;37(5):1076-1080.e1.
doi:10.1016/j.cli…
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psnet.ahrq.gov/node/39856/psn-pdf
December 21, 2014 - Patient perceptions of mistakes in ambulatory care.
December 21, 2014
Kistler CE, Walter LC, Mitchell M, et al. Patient perceptions of mistakes in ambulatory care. Arch Intern
Med. 2010;170(16):1480-7. doi:10.1001/archinternmed.2010.288.
https://psnet.ahrq.gov/issue/patient-perceptions-mistakes-ambulatory-care
Pat…
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psnet.ahrq.gov/node/41186/psn-pdf
January 03, 2017 - The costs of adverse drug events in community hospitals.
January 3, 2017
Hug BL, Keohane C, Seger DL, et al. The costs of adverse drug events in community hospitals. Jt Comm J
Qual Patient Saf. 2012;38(3):120-6.
https://psnet.ahrq.gov/issue/costs-adverse-drug-events-community-hospitals
Adverse drug events (ADEs) a…
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psnet.ahrq.gov/node/864370/psn-pdf
March 13, 2024 - How do patients and care partners describe diagnostic
uncertainty in an emergency department or urgent care
setting?
March 13, 2024
DeGennaro AP, Gonzalez N, Peterson SM, et al. How do patients and care partners describe diagnostic
uncertainty in an emergency department or urgent care setting? Diagnosis (Berl). 20…
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psnet.ahrq.gov/node/38309/psn-pdf
December 23, 2016 - Safely implementing health information and converging
technologies.
December 23, 2016
Safely implementing health information and converging technologies. Sentinel event alert. 2008;(42):1-4.
https://psnet.ahrq.gov/issue/safely-implementing-health-information-and-converging-technologies
As health information techno…