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psnet.ahrq.gov/node/47278/psn-pdf
August 15, 2018 - Drawing boundaries: the difficulty in defining clinical
reasoning.
August 15, 2018
Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning.
Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0000000000002142.
https://psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defi…
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psnet.ahrq.gov/node/73069/psn-pdf
March 24, 2021 - Evaluation of the quality of 'do not use' medication
abbreviation audits: a key enabler to successful
implementation of audit and feedback.
March 24, 2021
Li E, Marrandino J, Marshall S, et al. Evaluation of the quality of ‘do not use’ medication abbreviation
audits: a key enabler to successful implementation of a…
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psnet.ahrq.gov/node/74271/psn-pdf
January 19, 2022 - Improving shared situation awareness for high-risk
therapies in hospitalized children.
January 19, 2022
Sosa T, Mayer B, Chakkalakkal B, et al. Improving shared situation awareness for high-risk therapies in
hospitalized children. Hosp Pediatr. 2022;12(1):37-46. doi:10.1542/hpeds.2021-006193.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/46815/psn-pdf
April 29, 2018 - Designing and evaluating an automated system for real-
time medication administration error detection in a
neonatal intensive care unit.
April 29, 2018
Ni Y, Lingren T, Hall ES, et al. Designing and evaluating an automated system for real-time medication
administration error detection in a neonatal intensive care …
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psnet.ahrq.gov/node/34777/psn-pdf
February 16, 2011 - Systems errors versus physicians' errors: finding the
balance in medical education.
February 16, 2011
Casarett D, Helms C. Systems errors versus physicians' errors: finding the balance in medical education.
Acad Med. 1999;74(1):19-22.
https://psnet.ahrq.gov/issue/systems-errors-versus-physicians-errors-finding-bal…
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psnet.ahrq.gov/node/50424/psn-pdf
September 04, 2019 - From box ticking to the black box: the evolution of
operating room safety.
September 4, 2019
Goldenberg MG, Elterman D. From box ticking to the black box: the evolution of operating room safety.
World J Urol. 2019;38(6):1369-1372. doi:10.1007/s00345-019-02886-5.
https://psnet.ahrq.gov/issue/box-ticking-black-box-e…
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psnet.ahrq.gov/node/866247/psn-pdf
July 10, 2024 - Analysis of critical incident reports using natural
language processing.
July 10, 2024
Denecke K, Paula H. Analysis of critical incident reports using natural language processing. Stud Health
Technol Inform. 2024;313:1-6. doi:10.3233/shti240002.
https://psnet.ahrq.gov/issue/analysis-critical-incident-reports-using…
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psnet.ahrq.gov/node/865659/psn-pdf
April 24, 2024 - Diagnostic error in mental health: a review.
April 24, 2024
Bradford A, Meyer AND, Khan S, et al. Diagnostic error in mental health: a review. BMJ Qual Saf.
2024;33(10):663-672. doi:10.1136/bmjqs-2023-016996.
https://psnet.ahrq.gov/issue/diagnostic-error-mental-health-review
Diagnostic errors in mental health diso…
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psnet.ahrq.gov/node/60018/psn-pdf
March 04, 2020 - 2019 update on pediatric medical overuse: a systematic
review.
March 4, 2020
Money NM, Schroeder AR, Quinonez RA, et al. 2019 Update on Pediatric Medical Overuse. JAMA Pediatr.
2020;174(4):375-382. doi:10.1001/jamapediatrics.2019.5849.
https://psnet.ahrq.gov/issue/2019-update-pediatric-medical-overuse-systematic-r…
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psnet.ahrq.gov/node/43958/psn-pdf
April 22, 2015 - Non-intercepted dose errors in prescribing antineoplastic
treatment: a prospective, comparative cohort study.
April 22, 2015
Mattsson TO, Holm B, Michelsen H, et al. Non-intercepted dose errors in prescribing anti-neoplastic
treatment: a prospective, comparative cohort study. Ann Oncol. 2015;26(5):981-6.
doi:10.10…
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psnet.ahrq.gov/node/46474/psn-pdf
November 08, 2017 - Clearing the Error: Using Public Deliberation to Define
Patient Roles as Partners in the Diagnostic Process.
November 8, 2017
St. Paul, MN: Society to Improve Diagnosis in Medicine, Maxwell School of Citizenship and Public Affairs at
Syracuse University, and Jefferson Center; 2017.
https://psnet.ahrq.gov/issue/cle…
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psnet.ahrq.gov/node/45766/psn-pdf
February 08, 2017 - Prescription Drug Monitoring Programs: Evidence-based
Practices to Optimize Prescriber Use.
February 8, 2017
Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, Heller School for Social Policy
and Management at Brandeis University; 2016.
https://psnet.ahrq.gov/issue/prescription-drug-monit…
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psnet.ahrq.gov/node/43398/psn-pdf
July 30, 2014 - Strategies to prevent healthcare-associated infections
through hand hygiene.
July 30, 2014
Ellingson K, Haas JP, Aiello AE, et al. Strategies to prevent healthcare-associated infections through hand
hygiene. Infect Control Hosp Epidemiol. 2014;35(8):937-960. doi:10.1086/677145.
https://psnet.ahrq.gov/issue/strateg…
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psnet.ahrq.gov/node/866955/psn-pdf
October 16, 2024 - Adverse diagnostic events in hospitalised patients: a
single-centre, retrospective cohort study.
October 16, 2024
Dalal AK, Plombon S, Konieczny K, et al. Adverse diagnostic events in hospitalised patients: a single-
centre, retrospective cohort study. BMJ Qual Saf. 2024;Epub Oct 1. doi:10.1136/bmjqs-2024-017183.
…
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psnet.ahrq.gov/node/46447/psn-pdf
September 27, 2017 - Creating highly reliable accountable care organizations.
September 27, 2017
Vogus TJ, Singer SJ. Creating Highly Reliable Accountable Care Organizations. Med Care Res Rev.
2016;73(6):660-672.
https://psnet.ahrq.gov/issue/creating-highly-reliable-accountable-care-organizations
High reliability is a goal throughout …
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psnet.ahrq.gov/node/47581/psn-pdf
January 09, 2019 - Patient safety in inpatient psychiatry: a remaining frontier
for health policy.
January 9, 2019
Shields MC, Stewart MT, Delaney KR. Patient Safety In Inpatient Psychiatry: A Remaining Frontier For
Health Policy. Health Aff (Millwood). 2018;37(11):1853-1861. doi:10.1377/hlthaff.2018.0718.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/45371/psn-pdf
April 24, 2017 - Patient safety and workplace bullying: an integrative
review.
April 24, 2017
Houck NM, Colbert AM. Patient Safety and Workplace Bullying: An Integrative Review. J Nurs Care Qual.
2017;32(2):164-171. doi:10.1097/NCQ.0000000000000209.
https://psnet.ahrq.gov/issue/patient-safety-and-workplace-bullying-integrative-rev…
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psnet.ahrq.gov/node/46079/psn-pdf
June 28, 2017 - Death due to pharmacy compounding error reinforces
need for safety focus.
June 28, 2017
ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.
https://psnet.ahrq.gov/issue/death-due-pharmacy-compounding-error-reinforces-need-safety-focus
Compounding pharmacies prepare medicines for patients that a…
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psnet.ahrq.gov/node/45339/psn-pdf
August 10, 2016 - Hospital at night: an organizational design that provides
safer care at night.
August 10, 2016
Hamilton-Fairley D, Coakley J, Moss F. Hospital at night: an organizational design that provides safer care
at night. BMC Med Edu. 2014;14(Suppl 1):S17. doi:10.1186/1472-6920-14-S1-S17.
https://psnet.ahrq.gov/issue/hospi…
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psnet.ahrq.gov/node/44222/psn-pdf
December 04, 2016 - The Institute for Safe Medication Practices and poison
control centers: collaborating to prevent medication
errors and unintentional poisonings.
December 4, 2016
Vaida AJ. The Institute for Safe Medication Practices and Poison Control Centers: Collaborating to Prevent
Medication Errors and Unintentional Poisonings…