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psnet.ahrq.gov/node/42364/psn-pdf
September 18, 2013 - The pursuit of better diagnostic performance: a human
factors perspective.
September 18, 2013
Henriksen K, Brady J. The pursuit of better diagnostic performance: a human factors perspective. BMJ
Qual Saf. 2013;22(Suppl 2):ii1-ii5. doi:10.1136/bmjqs-2013-001827.
https://psnet.ahrq.gov/issue/pursuit-better-diagnosti…
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psnet.ahrq.gov/node/36431/psn-pdf
March 28, 2011 - Using the internet to deliver education on drug safety.
March 28, 2011
Franklin B, O'Grady K, Parr J, et al. Using the internet to deliver education on drug safety. Qual Saf Health
Care. 2006;15(5):329-33.
https://psnet.ahrq.gov/issue/using-internet-deliver-education-drug-safety
The project team implemented a web-…
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psnet.ahrq.gov/node/43318/psn-pdf
July 02, 2014 - Sign up to Safety.
July 2, 2014
National Health Service.
https://psnet.ahrq.gov/issue/sign-safety
Through a coordinated effort to set goals and devise plans to improve safety in hospitals, the Sign up to
Safety campaign aims to prevent 6000 patient deaths in the next 3 years in National Health Service
facilities.…
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psnet.ahrq.gov/node/40696/psn-pdf
December 01, 2011 - Rapid response systems: a prospective study of
response times.
December 1, 2011
Adelstein B-A, Piza MA, Nayyar V, et al. Rapid response systems: a prospective study of response times. J
Crit Care. 2011;26(6):635.e11-8. doi:10.1016/j.jcrc.2011.03.013.
https://psnet.ahrq.gov/issue/rapid-response-systems-prospective-…
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psnet.ahrq.gov/node/38341/psn-pdf
April 02, 2009 - CPOE: it don't come easy.
April 2, 2009
Anderson HJ. CPOE: it don't come easy. Health Data Manag. 2009;17(1):18-20, 22, 24 passim.
https://psnet.ahrq.gov/issue/cpoe-it-dont-come-easy
Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE)
systems could reduce medical errors…
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psnet.ahrq.gov/node/40568/psn-pdf
June 29, 2011 - Tubing misconnections: normalization of deviance.
June 29, 2011
Simmons D, Symes L, Guenter P, et al. Tubing misconnections: normalization of deviance. Nutr Clin Pract.
2011;26(3):286-293. doi:10.1177/0884533611406134.
https://psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance
Analyzing published ca…
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psnet.ahrq.gov/node/40903/psn-pdf
March 08, 2015 - Does your patient really understand?
March 8, 2015
Huff C. Does your patient really understand? Hospitals & health networks. 2011;85(10):34-5, 37-8, 2.
https://psnet.ahrq.gov/issue/does-your-patient-really-understand
This article discusses health literacy and describes an initiative to reduce gaps in understanding …
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psnet.ahrq.gov/node/44436/psn-pdf
October 30, 2017 - Overreaction.
October 30, 2017
Shell ER. Overreaction. Scientific American. 2015;313(5):28-9.
https://psnet.ahrq.gov/issue/overreaction
Reporting on how test inaccuracies can lead to misdiagnosis of food allergies in children and the potential
consequences, this magazine article describes a diagnostic tool to dete…
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psnet.ahrq.gov/node/39465/psn-pdf
May 08, 2018 - Latest heparin fatality speaks loudly—what have you
done to stop the bleeding?
May 8, 2018
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
https://psnet.ahrq.gov/issue/latest-heparin-fatality-speaks-loudly-what-have-you-done-stop-bleeding
Detailing a recent lethal overdose of heparin, this …
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psnet.ahrq.gov/node/42344/psn-pdf
September 24, 2016 - Strategies for preventing distractions and interruptions in
the OR.
September 24, 2016
Clark GJ. Strategies for preventing distractions and interruptions in the OR. AORN J. 2013;97(6):702-707.
doi:10.1016/j.aorn.2013.01.018.
https://psnet.ahrq.gov/issue/strategies-preventing-distractions-and-interruptions-or
Dist…
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psnet.ahrq.gov/node/37749/psn-pdf
July 16, 2018 - Practice advisory for the prevention and management of
operating room fires.
July 16, 2018
Fires AS of ATF on OR, Caplan RA, Barker SJ, et al. Practice advisory for the prevention and management
of operating room fires. Anesthesiology. 2008;108(5):786-801; quiz 971-2.
doi:10.1097/01.anes.0000299343.87119.a9.
htt…
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psnet.ahrq.gov/node/40668/psn-pdf
March 04, 2015 - Body CT: technical advances for improving safety.
March 4, 2015
Marin D, Nelson RC, Rubin GD, et al. Body CT: technical advances for improving safety. AJR Am J
Roentgenol. 2011;197(1):33-41. doi:10.2214/AJR.11.6755.
https://psnet.ahrq.gov/issue/body-ct-technical-advances-improving-safety
This article explores risk…
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psnet.ahrq.gov/node/35382/psn-pdf
October 05, 2005 - Rx for a better prescription. Hospital bans doctors from
using confusing medical abbreviations.
October 5, 2005
Hall J. Fredericksburg Times. September 25, 2005
https://psnet.ahrq.gov/issue/rx-better-prescription-hospital-bans-doctors-using-confusing-medical-
abbreviations
This article presents one hospital’s pro…
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psnet.ahrq.gov/node/46466/psn-pdf
July 11, 2018 - Distinct newborn identification requirement.
July 11, 2018
R3 Report. June 25, 2018;7:1-2.
https://psnet.ahrq.gov/issue/distinct-newborn-identification-requirement
Neonatal patients are at risk for misidentification due to communication challenges and lack of
distinguishable features. This report highlights new Jo…
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psnet.ahrq.gov/node/42830/psn-pdf
December 18, 2013 - How to Identify and Address Unsafe Conditions
Associated With Health IT.
December 18, 2013
Wallace C, Zimmer KP, Possanza L, Giannini R, Solomon R. Washington, DC: Office of the National
Coordinator for Health Information Technology; November 15, 2013.
https://psnet.ahrq.gov/issue/how-identify-and-address-unsafe-c…
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psnet.ahrq.gov/node/73431/psn-pdf
June 23, 2021 - Drive to Deprescribe.
June 23, 2021
The Society for Post-Acute and Long-Term Care Medicine.
https://psnet.ahrq.gov/issue/drive-deprescribe
Polypharmacy is a known challenge to patient safety. This collective program encourages long-term care
organizations, physicians, and pharmacists to take part in a learning net…
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psnet.ahrq.gov/node/42332/psn-pdf
June 12, 2013 - Quality improvement through implementation of
discharge order reconciliation.
June 12, 2013
Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order
reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050.
https://psnet.ahrq.gov/issue/quality-impr…
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psnet.ahrq.gov/node/42753/psn-pdf
November 20, 2013 - Dealing with a medical mistake: should physicians
apologize to patients?
November 20, 2013
Tabler NG Jr.
https://psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients
This article discusses how apologies address patients' needs when a medical mistake has occurred and
how such disclosur…
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digital.ahrq.gov/ahrq-funded-projects/integrating-contextual-factors-clinical-decision-support-reduce-contextual/citation/contextualizing
January 01, 2023 - Contextualizing care: An essential and measurable clinical competency.
Citation
Weiner SJ. Contextualizing care: An essential and measurable clinical competency. Patient Educ Couns. 2022 Mar;105(3):594-598. doi: 10.1016/j.pec.2021.06.016. Epub 2021 Jun 15. PMID: 34158194.
Link
https://pubmed.n…
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psnet.ahrq.gov/node/47556/psn-pdf
November 28, 2018 - Improving Diagnosis.
November 28, 2018
Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70.
https://psnet.ahrq.gov/issue/improving-diagnosis
This special issue raises awareness of challenges to reducing diagnostic error. Articles discuss insights
from experts about how to improve diagnosis, t…