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psnet.ahrq.gov/node/34693/psn-pdf
February 10, 2011 - Effect of outcome on physician judgments of
appropriateness of care.
February 10, 2011
Caplan RA, Posner KL, Cheney FW. Effect of outcome on physician judgments of appropriateness of care.
JAMA. 1991;265(15):1957-60.
https://psnet.ahrq.gov/issue/effect-outcome-physician-judgments-appropriateness-care
The authors …
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psnet.ahrq.gov/node/38290/psn-pdf
February 17, 2011 - Revisiting duty-hour limits — IOM recommendations for
patient safety and resident education.
February 17, 2011
Iglehart JK. Revisiting duty-hour limits--IOM recommendations for patient safety and resident education. N
Engl J Med. 2008;359(25):2633-5. doi:10.1056/NEJMp0808736.
https://psnet.ahrq.gov/issue/revisitin…
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psnet.ahrq.gov/node/45599/psn-pdf
July 02, 2017 - Inattentional blindness and failures to rescue the
deteriorating patient in critical care, emergency and
perioperative settings: four case scenarios.
July 2, 2017
Jones A, Johnstone M-J. Inattentional blindness and failures to rescue the deteriorating patient in critical
care, emergency and perioperative settings:…
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psnet.ahrq.gov/node/45791/psn-pdf
September 01, 2018 - Changes in physician practice patterns after
implementation of a communication-and-resolution
program.
September 1, 2018
Helmchen LA, Lambert BL, McDonald TB. Changes in Physician Practice Patterns after Implementation of
a Communication-and-Resolution Program. Health Serv Res. 2016;51(Suppl 3):2516-2536.
doi:10.…
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psnet.ahrq.gov/node/38943/psn-pdf
November 25, 2009 - Medical error reporting, patient safety, and the physician.
November 25, 2009
Anderson B, Stumpf PG, Schulkin J. Medical Error Reporting, Patient Safety, and the Physician. J Patient
Saf. 2009;5(3):176-179. doi:10.1097/pts.0b013e3181b320b0.
https://psnet.ahrq.gov/issue/medical-error-reporting-patient-safety-and-phy…
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psnet.ahrq.gov/node/46544/psn-pdf
September 12, 2018 - Interventions to improve follow-up of laboratory test
results pending at discharge: a systematic review.
September 12, 2018
Whitehead NS, Williams L, Meleth S, et al. Interventions to Improve Follow-Up of Laboratory Test Results
Pending at Discharge: A Systematic Review. J Hosp Med. 2018. doi:10.12788/jhm.2944.
ht…
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psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
September 29, 2011 - Patient Safety and Adherence to Self-Administered Medications
Citation Text:
Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011…
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psnet.ahrq.gov/node/46060/psn-pdf
October 31, 2017 - Do hospitals support second victims? Collective insights
from patient safety leaders in Maryland.
October 31, 2017
Edrees HH, Morlock L, Wu AW. Do Hospitals Support Second Victims? Collective Insights From Patient
Safety Leaders in Maryland. Jt Comm J Qual Saf. 2017;43(9):471-483. doi:10.1016/j.jcjq.2017.01.008.
h…
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psnet.ahrq.gov/node/47379/psn-pdf
November 14, 2018 - Analysis of medication therapy discontinuation orders in
new electronic prescriptions and opportunities for
implementing CancelRx.
November 14, 2018
Yang Y, Ward-Charlerie S, Kashyap N, et al. Analysis of medication therapy discontinuation orders in new
electronic prescriptions and opportunities for implementing C…
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psnet.ahrq.gov/node/47248/psn-pdf
September 26, 2018 - Frequency and nature of potentially harmful preventable
problems in primary care from the patient's perspective
with clinician review: a population-level survey in Great
Britain.
September 26, 2018
Stocks SJ, Donnelly A, Esmail A, et al. Frequency and nature of potentially harmful preventable problems
in primary …
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psnet.ahrq.gov/node/35571/psn-pdf
April 06, 2011 - Overestimation of clinical diagnostic performance caused
by low necropsy rates.
April 6, 2011
Shojania KG, Burton EC, McDonald KM, et al. Overestimation of clinical diagnostic performance caused by
low necropsy rates. Qual Saf Health Care. 2005;14(6):408-13.
https://psnet.ahrq.gov/issue/overestimation-clinical-dia…
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psnet.ahrq.gov/node/44043/psn-pdf
September 20, 2017 - Incident learning in pursuit of high reliability:
implementing a comprehensive, low-threshold reporting
program in a large, multisite radiation oncology
department.
September 20, 2017
Gabriel PE, Volz E, Bergendahl HW, et al. Incident learning in pursuit of high reliability: implementing a
comprehensive, low-thre…
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psnet.ahrq.gov/node/46559/psn-pdf
December 22, 2018 - Effect of promoting high-quality staff interactions on fall
prevention in nursing homes: a cluster-randomized trial.
December 22, 2018
Colón-Emeric CS, Corazzini K, McConnell ES, et al. Effect of Promoting High-Quality Staff Interactions on
Fall Prevention in Nursing Homes: A Cluster-Randomized Trial. JAMA Intern M…
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psnet.ahrq.gov/node/44165/psn-pdf
May 27, 2015 - Unplanned return to theater: a quality of care and risk
management index?
May 27, 2015
Pujol N, Merrer J, Lemaire B, et al. Unplanned return to theater: A quality of care and risk management
index? Orthop Traumatol Surg Res. 2015;101(4):399-403. doi:10.1016/j.otsr.2015.03.013.
https://psnet.ahrq.gov/issue/unplanne…
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psnet.ahrq.gov/node/35877/psn-pdf
July 23, 2010 - National Quality Forum 30 safe practices: priority and
progress in Iowa hospitals.
July 23, 2010
Ward MM, Evans TC, Spies AJ, et al. National Quality Forum 30 safe practices: priority and progress in
Iowa hospitals. Am J Med Qual. 2006;21(2):101-8.
https://psnet.ahrq.gov/issue/national-quality-forum-30-safe-practi…
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psnet.ahrq.gov/node/43678/psn-pdf
April 22, 2015 - 'Connecting the dots': leveraging visual analytics to make
sense of patient safety event reports.
April 22, 2015
Ratwani RM, Fong A. 'Connecting the dots': leveraging visual analytics to make sense of patient safety
event reports. J Am Med Inform Assoc. 2015;22(2):312-7. doi:10.1136/amiajnl-2014-002963.
https://ps…
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psnet.ahrq.gov/node/34872/psn-pdf
February 09, 2011 - Hospital nurse staffing and patient mortality, nurse
burnout, and job dissatisfaction.
February 9, 2011
Aiken LH, Clarke S, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job
dissatisfaction. JAMA. 2002;288(16):1987-93.
https://psnet.ahrq.gov/issue/hospital-nurse-staffing-and-p…
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psnet.ahrq.gov/node/34656/psn-pdf
May 27, 2011 - A look into the nature and causes of human errors in the
intensive care unit.
May 27, 2011
Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care
unit. Crit Care Med. 1995;23(2):294-300.
https://psnet.ahrq.gov/issue/look-nature-and-causes-human-errors-intensive-…
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - Annual Perspective
Computerized Provider Order Entry and Patient Safety
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien…