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psnet.ahrq.gov/node/47626/psn-pdf
February 13, 2019 - The effect of a clinical decision support for pending
laboratory results at emergency department discharge.
February 13, 2019
Driver BE, Scharber SK, Fagerstrom ET, et al. The Effect of a Clinical Decision Support for Pending
Laboratory Results at Emergency Department Discharge. J Emerg Med. 2019;56(1):109-113.
do…
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psnet.ahrq.gov/node/45670/psn-pdf
November 16, 2016 - Not thinking clearly? Play a game, seriously!
November 16, 2016
Mohan D, Schell J, Angus DC. Not Thinking Clearly? Play a Game, Seriously!. JAMA. 2016;316(18):1867-
1868. doi:10.1001/jama.2016.14174.
https://psnet.ahrq.gov/issue/not-thinking-clearly-play-game-seriously
Heuristics enable experts to build off their …
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psnet.ahrq.gov/node/36964/psn-pdf
March 24, 2011 - Patients use an internet technology to report when things
go wrong.
March 24, 2011
Wasson JH, MacKenzie TA, Hall M. Patients use an internet technology to report when things go wrong.
Qual Saf Health Care. 2007;16(3):213-5.
https://psnet.ahrq.gov/issue/patients-use-internet-technology-report-when-things-go-wrong
…
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psnet.ahrq.gov/node/846152/psn-pdf
March 15, 2023 - Coworker abuse in healthcare: voices of mistreated
workers.
March 15, 2023
Evans WR, Mullen DM, Burke-Smalley L. Coworker abuse in healthcare: voices of mistreated workers. J
Health Organ Manag. 2023;37(2):236-249. doi:10.1108/jhom-05-2022-0131.
https://psnet.ahrq.gov/issue/coworker-abuse-healthcare-voices-mistrea…
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psnet.ahrq.gov/node/47439/psn-pdf
January 17, 2019 - Prevalence of and factors associated with patient
nondisclosure of medically relevant information to
clinicians.
January 17, 2019
Levy AG, Scherer AM, Zikmund-Fisher BJ, et al. Prevalence of and Factors Associated With Patient
Nondisclosure of Medically Relevant Information to Clinicians. JAMA Netw Open. 2018;1(7)…
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psnet.ahrq.gov/node/50922/psn-pdf
February 19, 2020 - An Organisation Losing its Memory? Patient Safety
Alerts: Implementation, Monitoring and Regulation in
England
February 19, 2020
Cousins D. Croydon, UK: Accidents against Medical Accidents; 2020.
https://psnet.ahrq.gov/issue/organisation-losing-its-memory-patient-safety-alerts-implementation-
monitoring-and-regul…
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psnet.ahrq.gov/node/867182/psn-pdf
November 20, 2024 - Combining multiple large language models improves
diagnostic accuracy.
November 20, 2024
Barabucci G, Shia V, Chu ES, et al. Combining multiple large language models improves diagnostic
accuracy. NEJM AI. 2024;1(11):AIcs2400502. doi:10.1056/aics2400502.
https://psnet.ahrq.gov/issue/combining-multiple-large-languag…
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psnet.ahrq.gov/node/35575/psn-pdf
April 11, 2011 - Parental preferences for error disclosure, reporting, and
legal action after medical error in the care of their
children.
April 11, 2011
Hobgood C, Tamayo-Sarver JH, Elms A, et al. Parental preferences for error disclosure, reporting, and
legal action after medical error in the care of their children. Pediatrics. …
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psnet.ahrq.gov/node/74870/psn-pdf
April 11, 2022 - Proposed 2022 CDC clinical practice guideline for
prescribing opioids. A notice by the Centers for Disease
Control and Prevention.
February 23, 2022
Fed Register. February 10, 2022;87: 7838-7840.
https://psnet.ahrq.gov/issue/proposed-2022-cdc-clinical-practice-guideline-prescribing-opioids-notice-
centers-disease…
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psnet.ahrq.gov/node/855095/psn-pdf
November 08, 2023 - Identifying barriers and enablers for a robust independent
second check of medication in adult intensive care.
November 8, 2023
Milic V, Cameron L, Jones C. Identifying barriers and enablers for a robust independent second check of
medication in adult intensive care. Br J Nurs. 2023;32(17):840-848. doi:10.12968/bjo…
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psnet.ahrq.gov/node/60649/psn-pdf
July 01, 2020 - The differences between human error, at-risk behavior,
and reckless behavior are key to a just culture.
July 1, 2020
The differences between human error, at-risk behavior, and reckless behavior are key to a just culture.
ISMP Medication Safety Alert! Acute Care Edition. June 2020;25(12).
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/47923/psn-pdf
April 17, 2019 - Improving employee voice about transgressive or
disruptive behavior: a case study.
April 17, 2019
Dixon-Woods M, Campbell A, Martin G, et al. Improving Employee Voice About Transgressive or Disruptive
Behavior: A Case Study. Acad Med. 2019;94(4):579-585. doi:10.1097/ACM.0000000000002447.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/35418/psn-pdf
June 14, 2011 - Anatomic pathology databases and patient safety.
June 14, 2011
Raab SS, Grzybicki DM, Zarbo RJ, et al. Anatomic pathology databases and patient safety. Arch Pathol
Lab Med. 2005;129(10):1246-1251.
https://psnet.ahrq.gov/issue/anatomic-pathology-databases-and-patient-safety
This AHRQ-funded project describes the de…
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psnet.ahrq.gov/node/35909/psn-pdf
October 07, 2008 - Committed to Safety: Ten Case Studies on Reducing
Harm to Patients.
October 7, 2008
McCarthy D, Blumenthal D. New York, NY: Commonwealth Fund; 2006.
https://psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients
This report presents ten case studies to illustrate interventions that address p…
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psnet.ahrq.gov/node/47832/psn-pdf
February 27, 2019 - Another round of the blame game: a paralyzing criminal
indictment that recklessly "overrides" just culture.
February 27, 2019
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
https://psnet.ahrq.gov/issue/another-round-blame-game-paralyzing-criminal-indictment-recklessly-
overrides-just-cultu…
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psnet.ahrq.gov/node/41839/psn-pdf
November 27, 2012 - A systematic approach to the identification and
classification of near-miss events on labor and delivery in
a large, national health care system.
November 27, 2012
Clark SL, Meyers JA, Frye DR, et al. A systematic approach to the identification and classification of near-
miss events on labor and delivery in a lar…
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psnet.ahrq.gov/node/47773/psn-pdf
April 17, 2019 - People, systems and safety: resilience and excellence in
healthcare practice.
April 17, 2019
Smith AF, Plunkett E. People, systems and safety: resilience and excellence in healthcare practice.
Anaesthesia. 2019;74(4):508-517. doi:10.1111/anae.14519.
https://psnet.ahrq.gov/issue/people-systems-and-safety-resilience…
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psnet.ahrq.gov/node/43532/psn-pdf
June 23, 2017 - The Second Victim Experience and Support Tool:
validation of an organizational resource for assessing
second victim effects and the quality of support
resources.
June 23, 2017
Burlison JD, Scott SD, Browne EK, et al. The Second Victim Experience and Support Tool: validation of an
organizational resource for asses…
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psnet.ahrq.gov/node/60261/psn-pdf
April 22, 2020 - Hospital Experiences Responding to the COVID-19
Pandemic: Results of a National Pulse Survey March 23-
27, 2020.
April 22, 2020
Washington DC: Office of the Inspector General; April 3, 2020. Report no. OEI-06-20-00300.
https://psnet.ahrq.gov/issue/hospital-experiences-responding-covid-19-pandemic-results-national-…
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psnet.ahrq.gov/node/44067/psn-pdf
June 02, 2015 - Surgical team member assessment of the safety of
surgery practice in 38 South Carolina hospitals.
June 2, 2015
Singer SJ, Jiang W, Huang LC, et al. Surgical team member assessment of the safety of surgery practice
in 38 South Carolina hospitals. Med Care Res Rev. 2015;72(3):298-323. doi:10.1177/1077558715577479.
h…