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psnet.ahrq.gov/node/50729/psn-pdf
December 11, 2019 - Improving Diagnostic Quality & Safety/Reducing
Diagnostic Error: Measurement Considerations.
December 11, 2019
Washington DC; National Quality Forum: October 28, 2019.
https://psnet.ahrq.gov/issue/improving-diagnostic-quality-safetyreducing-diagnostic-error-measurement-
considerations
Efforts to track, understand…
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psnet.ahrq.gov/node/47954/psn-pdf
August 07, 2019 - Special Issue on Resilience Engineering and High
Reliability Organizations.
August 7, 2019
Wears RL, Roberts KH, eds. Safety Sci. 2019;117;458-533.
https://psnet.ahrq.gov/issue/special-issue-resilience-engineering-and-high-reliability-organizations
Resilience is an organizational characteristic that enables indivi…
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psnet.ahrq.gov/node/867450/psn-pdf
January 08, 2025 - Advancing Health Care Safety for All.
January 8, 2025
Advancing Health Care Safety for All. Centers for Medicare and Medicaid Services. 2024.
https://psnet.ahrq.gov/issue/advancing-health-care-safety-all
As one element of a national program to improve care quality, the Centers for Medicare and Medicaid
Services (C…
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psnet.ahrq.gov/node/34979/psn-pdf
June 22, 2009 - The WHO World Alliance for Patient Safety: a new
challenge or an old one neglected?
June 22, 2009
Edwards R. The WHO World Alliance for Patient Safety: a new challenge or an old one neglected? Drug
Saf. 2005;28(5):379-86.
https://psnet.ahrq.gov/issue/who-world-alliance-patient-safety-new-challenge-or-old-one-negle…
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psnet.ahrq.gov/node/45503/psn-pdf
October 29, 2017 - All CLEAR? Preparing for IT downtime.
October 29, 2017
Kashiwagi DT, Sexton MD, Graves ES, et al. All CLEAR? Preparing for IT Downtime. Am J Med Qual.
2017;32(5):547-551. doi:10.1177/1062860616667546.
https://psnet.ahrq.gov/issue/all-clear-preparing-it-downtime
Due to the increasing integration of health care proc…
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psnet.ahrq.gov/node/842432/psn-pdf
January 11, 2023 - Medication errors: the year in review: January through
December 2021.
January 11, 2023
Pharmacy Practice News Special Edition. December 13, 2022: 43-54.
https://psnet.ahrq.gov/issue/medication-errors-year-review-january-through-december-2021
Medication errors continue to occur despite long-standing efforts to redu…
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psnet.ahrq.gov/node/847057/psn-pdf
April 05, 2023 - Implement strategies to prevent persistent medication
errors and hazards.
April 5, 2023
ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4.
https://psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards
Medication mistakes are recognized contributors to p…
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psnet.ahrq.gov/node/73225/psn-pdf
May 05, 2021 - Black or 'other'? Doctors may be relying on race to make
decisions about your health.
May 5, 2021
Smith J, Spodak C. CNN. April 25, 2021.
https://psnet.ahrq.gov/issue/black-or-other-doctors-may-be-relying-race-make-decisions-about-your-health
Race-adjusted decision making tools perpetuate the potential for diagnos…
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psnet.ahrq.gov/node/48041/psn-pdf
July 10, 2019 - Accuracy of computer-aided diagnosis of melanoma: a
meta-analysis.
July 10, 2019
Dick V, Sinz C, Mittlböck M, et al. Accuracy of Computer-Aided Diagnosis of Melanoma. JAMA Dermatol.
2019;155(11):1291-1299. doi:10.1001/jamadermatol.2019.1375.
https://psnet.ahrq.gov/issue/accuracy-computer-aided-diagnosis-melanoma-m…
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psnet.ahrq.gov/node/50758/psn-pdf
December 18, 2019 - Still Not Safe: Patient Safety and the Middle-Managing of
American Medicine.
December 18, 2019
Wears R, Sutcliffe K. New York, NY: Oxford University Press; 2019. ISBN: 9780190271268.
https://psnet.ahrq.gov/issue/still-not-safe-patient-safety-and-middle-managing-american-medicine
The modern patient safety movement …
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psnet.ahrq.gov/node/60742/psn-pdf
July 29, 2020 - Doctors and dentists still flooding U.S. with opioid
prescriptions.
July 29, 2020
Mann B. Doctors and dentists still flooding U.S. with opioid prescriptions. National Public Radio. 2020;July
17.
https://psnet.ahrq.gov/issue/doctors-and-dentists-still-flooding-us-opioid-prescriptions
Despite efforts to reduce opio…
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psnet.ahrq.gov/node/43778/psn-pdf
April 22, 2015 - Meet the cancer patient in room 52: his name is Joseph,
but call him Joe.
April 22, 2015
Sun LH.
https://psnet.ahrq.gov/issue/meet-cancer-patient-room-52-his-name-joseph-call-him-joe
This newspaper article reports on a pilot program which involved redesigning intensive care unit processes
to enhance staff knowled…
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psnet.ahrq.gov/node/50594/psn-pdf
October 30, 2019 - Pharmacist linkage in care transitions: from academic
medical center to community.
October 30, 2019
Bloodworth LS, Malinowski SS, Lirette ST, et al. Pharmacist linkage in care transitions: from academic
medical center to community. J Am Pharm Assoc . 2019;59(6):896-904. doi:10.1016/j.japh.2019.08.011.
https://psne…
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psnet.ahrq.gov/node/47386/psn-pdf
September 19, 2018 - Active-shooter response at a health care facility.
September 19, 2018
Inaba K, Eastman AL, Jacobs LM, et al. Active-Shooter Response at a Health Care Facility. N Engl J Med.
2018;379(6):583-586. doi:10.1056/NEJMms1800582.
https://psnet.ahrq.gov/issue/active-shooter-response-health-care-facility
Physical and verbal…
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psnet.ahrq.gov/node/39119/psn-pdf
November 25, 2009 - Effect of a weight-based prescribing method within an
electronic health record on prescribing errors.
November 25, 2009
Ginzburg R, Barr WB, Harris M, et al. Effect of a weight-based prescribing method within an electronic
health record on prescribing errors. Am J Health Syst Pharm. 2009;66(22):2037-41.
doi:10.214…
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psnet.ahrq.gov/node/47925/psn-pdf
August 21, 2019 - Second victims and mindfulness: a systematic review.
August 21, 2019
S Miller C, Scott SD, Beck M. Second victims and mindfulness: a systematic review. J Patient Saf Risk
Manag. 2019;24(3):108-117. doi:10.1177/2516043519838176.
https://psnet.ahrq.gov/issue/second-victims-and-mindfulness-systematic-review
The secon…
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psnet.ahrq.gov/node/72598/psn-pdf
January 01, 2021 - Hospital medication errors: a cross sectional study.
December 23, 2020
ISAACS AN, Ch'ng K, DELHIWALE N, et al. Hospital medication errors: a cross-sectional study. Int J Qual
Health Care. 2021;33(1):mzaa136. doi:10.1093/intqhc/mzaa136.
https://psnet.ahrq.gov/issue/hospital-medication-errors-cross-sectional-study
R…
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psnet.ahrq.gov/node/43379/psn-pdf
August 14, 2014 - Unit of measurement used and parent medication dosing
errors.
August 14, 2014
Yin S, Dreyer BP, Ugboaja DC, et al. Unit of measurement used and parent medication dosing errors.
Pediatrics. 2014;134(2):e354-61. doi:10.1542/peds.2014-0395.
https://psnet.ahrq.gov/issue/unit-measurement-used-and-parent-medication-dosi…
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psnet.ahrq.gov/node/60192/psn-pdf
April 01, 2020 - Effective Reporting Could Improve Safe Use of Electronic
Health Records.
April 1, 2020
Philadelphia, PA: Pew Charitable Trusts; March 2020.
https://psnet.ahrq.gov/issue/effective-reporting-could-improve-safe-use-electronic-health-records
Electronic health records both enhance and challenge the safety of care proce…
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psnet.ahrq.gov/node/38420/psn-pdf
February 18, 2009 - Effect of short-term pretrial practice on surgical
proficiency in simulated environments: a randomized trial
of the "preoperative warm-up" effect.
February 18, 2009
Kahol K, Satava RM, Ferrara JJ, et al. Effect of Short-Term Pretrial Practice on Surgical Proficiency in
Simulated Environments: A Randomized Trial of…