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psnet.ahrq.gov/node/72751/psn-pdf
February 17, 2021 - The critical need for nursing education to address the
diagnostic process.
February 17, 2021
Gleason KT, Harkless G, Stanley J, et al. The critical need for nursing education to address the diagnostic
process. Nurs Outlook. 2021;69(3):362-369. doi:10.1016/j.outlook.2020.12.005.
https://psnet.ahrq.gov/issue/critica…
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psnet.ahrq.gov/node/46160/psn-pdf
June 07, 2017 - ISMP Guidelines for Optimizing Safe Subcutaneous
Insulin Use in Adults.
June 7, 2017
Horsham, PA: Institute for Safe Medication Practices; May 2017.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults
Insulin is a widely used medication that can contribute to serious patien…
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psnet.ahrq.gov/node/46444/psn-pdf
December 19, 2017 - Nil per os orders for imaging: a teachable moment.
December 19, 2017
Wickerham AL, Schultz EJ, Lewine EB. Nil per Os Orders for Imaging: A Teachable Moment. JAMA Intern
Med. 2017;177(11):1670-1671. doi:10.1001/jamainternmed.2017.3943.
https://psnet.ahrq.gov/issue/nil-os-orders-imaging-teachable-moment
Patients are…
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psnet.ahrq.gov/node/837593/psn-pdf
June 29, 2022 - Adverse event reporting priorities: an integrative review.
June 29, 2022
Falcone ML, Van Stee SK, Tokac U, et al. Adverse event reporting priorities: an integrative review. J
Patient Saf. 2022;18(4):e727-e740. doi:10.1097/pts.0000000000000945.
https://psnet.ahrq.gov/issue/adverse-event-reporting-priorities-integrat…
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psnet.ahrq.gov/node/45486/psn-pdf
September 14, 2016 - Addressing nurse fatigue to promote safety and health:
joint responsibilities of registered nurses and employers
to reduce risks.
September 14, 2016
Silver Spring, MD: American Nurses Association; September 2014.
https://psnet.ahrq.gov/issue/addressing-nurse-fatigue-promote-safety-and-health-joint-responsibilities…
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psnet.ahrq.gov/node/47943/psn-pdf
May 20, 2019 - Governing the safety of artificial intelligence in
healthcare.
May 20, 2019
Macrae C. Governing the safety of artificial intelligence in healthcare. BMJ Qual Saf. 2019;28(6):495-498.
doi:10.1136/bmjqs-2019-009484.
https://psnet.ahrq.gov/issue/governing-safety-artificial-intelligence-healthcare
The unintended risk…
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www.ahrq.gov/patients-consumers/patient-involvement/navigating-the-health-care-system.html
September 01, 2015 - Navigating the Health Care System
After having led AHRQ for a decade, Dr. Carolyn Clancy left the Agency in 2013 to begin work as Assistant Deputy Undersecretary for Health, Patient Safety, Quality, and Value at the Veterans Administration. First and foremost a physician, Dr. Clancy was at AHRQ for 23 years.
…
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psnet.ahrq.gov/node/837024/psn-pdf
May 04, 2022 - The potential for leveraging machine learning to filter
medication alerts.
May 4, 2022
Liu S, Kawamoto K, Del Fiol G, et al. The potential for leveraging machine learning to filter medication
alerts. J Am Med Inform Assoc. 2022;29(5):891-899. doi:10.1093/jamia/ocab292.
https://psnet.ahrq.gov/issue/potential-levera…
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psnet.ahrq.gov/node/48068/psn-pdf
June 12, 2019 - Health Professions Education.
June 12, 2019
Dhaliwal G, Olson APJ, Singhal G, eds. Diagnosis (Berl). 2019;6(2):75-185.
https://psnet.ahrq.gov/issue/health-professions-education
Clinical and educational environments are increasingly focusing on improving diagnosis. This special issue
explores an overarching approac…
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psnet.ahrq.gov/node/72591/psn-pdf
December 23, 2020 - Bias and racism teaching rounds at an academic medical
center.
December 23, 2020
Capers Q, Bond DA, Nori US. Bias and racism teaching rounds at an academic medical center. Chest.
2020;158(6):2688-2694. doi:10.1016/j.chest.2020.08.2073.
https://psnet.ahrq.gov/issue/bias-and-racism-teaching-rounds-academic-medical-c…
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psnet.ahrq.gov/node/40385/psn-pdf
May 21, 2019 - A comprehensive obstetrics patient safety program
improves safety climate and culture.
May 21, 2019
Pettker CM, Thung SF, Raab CA, et al. A comprehensive obstetrics patient safety program improves safety
climate and culture. Am J Obstet Gynecol. 2011;204(3):216.e1-6. doi:10.1016/j.ajog.2010.11.004.
https://psnet.a…
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psnet.ahrq.gov/node/47718/psn-pdf
March 20, 2019 - Impact of patient safety culture on missed nursing care
and adverse patient events.
March 20, 2019
Hessels AJ, Paliwal M, Weaver SH, et al. Impact of Patient Safety Culture on Missed Nursing Care and
Adverse Patient Events. J Nurs Care Qual. 2019;34(4):287-294. doi:10.1097/NCQ.0000000000000378.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/33927/psn-pdf
June 23, 2015 - Errors, incidents and accidents in anaesthetic practice.
June 23, 2015
Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and
accidents in anaesthetic practice. Anaesth Intensive Care. 1993;21(5):506-19.
https://psnet.ahrq.gov/issue/errors-incidents-and-accidents-anae…
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psnet.ahrq.gov/node/47851/psn-pdf
May 22, 2019 - Communication and Resolution After an Adverse Health
Care Incident.
May 22, 2019
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
https://psnet.ahrq.gov/issue/communication-and-resolution-after-adverse-health-care-incident
Communication-and-resolution mechanisms are seen as important approache…
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psnet.ahrq.gov/node/60604/psn-pdf
June 17, 2020 - The limits of current A.I. in health care: patient safety
policing in hospitals.
June 17, 2020
Furrow BR. NE Univ Law Rev. 2020;12(1):1-55.
https://psnet.ahrq.gov/issue/limits-current-ai-health-care-patient-safety-policing-hospitals
Artificial intelligence (AI) has the potential to improve the use of big data to e…
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psnet.ahrq.gov/node/39218/psn-pdf
January 13, 2010 - Prolonged hospital stay and the resident duty hour rules
of 2003.
January 13, 2010
Silber JH, Rosenbaum PR, Rosen AK, et al. Prolonged Hospital Stay and the Resident Duty Hour Rules of
2003. Med Care. 2009;47(12). doi:10.1097/mlr.0b013e3181adcbff.
https://psnet.ahrq.gov/issue/prolonged-hospital-stay-and-resident-d…
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psnet.ahrq.gov/node/839327/psn-pdf
December 05, 2024 - The National Healthcare System Action Alliance for
Patient and Workforce Safety.
December 5, 2024
US Department of Health and Human Services.
https://psnet.ahrq.gov/issue/national-healthcare-system-action-alliance-advance-patient-safety
The large system change required to reduce patient harm requires multi-stakeho…
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psnet.ahrq.gov/node/836761/psn-pdf
March 16, 2022 - Complexity bias in the prevention of iatrogenic injury:
why specific harms may inhibit performance.
March 16, 2022
Padula WV, Armstrong DG, Goldman DP. Complexity bias in the prevention of iatrogenic injury: why
specific harms may inhibit performance. Mayo Clin Proc. 2022;97(2):221-224.
doi:10.1016/j.mayocp.2021.1…
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psnet.ahrq.gov/node/35176/psn-pdf
June 23, 2009 - Mapping changes in surgical mortality over 9 years by
peer review audit.
June 23, 2009
Thompson A, Ashraf Z, Burton H, et al. Mapping changes in surgical mortality over 9 years by peer review
audit. Br J Surg. 2005;92(11):1449-52.
https://psnet.ahrq.gov/issue/mapping-changes-surgical-mortality-over-9-years-peer-re…
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psnet.ahrq.gov/node/836833/psn-pdf
March 30, 2022 - As a nurse faces prison for a deadly error, her colleagues
worry: could I be next?
March 30, 2022
Kelman B. Kaiser Health News. March 22, 2022
https://psnet.ahrq.gov/issue/nurse-faces-prison-deadly-error-her-colleagues-worry-could-i-be-next
Criminalization of medical mistakes typifies the blame-focused approach pa…