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psnet.ahrq.gov/node/49464/psn-pdf
December 27, 2020 - Recognizing this inherent risk in the procedure, experts have offered
suggestions specific to the handling
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psnet.ahrq.gov/node/60064/psn-pdf
March 18, 2020 - Providing Safe, High-Quality Maternity Care in Rural US
Hospitals. IHI Innovation Report.
March 18, 2020
Laderman M, Renton M. Boston, MA: Institute for Healthcare Improvement; 2020.
https://psnet.ahrq.gov/issue/providing-safe-high-quality-maternity-care-rural-us-hospitals-ihi-innovation-
report
Maternal care saf…
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psnet.ahrq.gov/node/838135/psn-pdf
January 01, 2023 - The fallacy of a single diagnosis.
September 21, 2022
Redelmeier DA, Shafir E. The fallacy of a single diagnosis. Med Decis Making. 2023;43(2):183-190.
doi:10.1177/0272989x221121343.
https://psnet.ahrq.gov/issue/fallacy-single-diagnosis
Premature closure occurs when clinicians accept a diagnosis before it has been…
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - Specific suggestions include reminding caregivers about diabetes, wearing a diabetes identification tag … Specific suggestions include having your doctor explain what you can expect after leaving the hospital
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psnet.ahrq.gov/node/74097/psn-pdf
November 24, 2021 - Inattentional blindness in anesthesiology: a gorilla is
worth one thousand words.
November 24, 2021
De Cassai A, Negro S, Geraldini F, et al. Inattentional blindness in anesthesiology: a gorilla is worth one
thousand words. PLoS One. 2021;16(9):e0257508. doi:10.1371/journal.pone.0257508.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/issue/survey-suggests-possible-downward-trend-identifying-key-drugsdrug-classes-high-alert
July 30, 2014 - Newspaper/Magazine Article
Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications.
Citation Text:
Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications. ISMP Medication Safety Alert! Acute …
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psnet.ahrq.gov/node/74863/psn-pdf
February 23, 2022 - Factors associated with missed nursing care and nurse-
assessed quality of care during the COVID-19 pandemic.
February 23, 2022
Labrague LJ, Santos JAA, Fronda DC. Factors associated with missed nursing care and nurse?assessed
quality of care during the COVID?19 pandemic. J Nurs Manag. 2022;30(1):62-70. doi:10.1111…
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psnet.ahrq.gov/node/60325/psn-pdf
May 13, 2020 - Impacts of operational failures on primary care
physicians' work: a critical interpretive synthesis of the
literature.
May 13, 2020
Sinnott C, Georgiadis A, Park J, et al. Impacts of operational failures on primary care physicians' work: a
critical interpretive synthesis of the literature. Ann Fam Med. 2020;18(2):…
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psnet.ahrq.gov/node/842772/psn-pdf
January 18, 2023 - Short- and long-term effects of an electronic medication
management system on paediatric prescribing errors.
January 18, 2023
Westbrook JI, Li L, Raban MZ, et al. Short- and long-term effects of an electronic medication management
system on paediatric prescribing errors. NPJ Digit Med. 2022;5(1):179. doi:10.1038/s4…
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psnet.ahrq.gov/node/836745/psn-pdf
March 16, 2022 - Estimation of breast cancer overdiagnosis in a U.S. breast
screening cohort.
March 16, 2022
Ryser MD, Lange J, Inoue LYT, et al. Estimation of breast cancer overdiagnosis in a U.S. breast screening
cohort. Ann Intern Med. 2022;175(4):471-478. doi:10.7326/m21-3577.
https://psnet.ahrq.gov/issue/estimation-breast-can…
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psnet.ahrq.gov/node/840147/psn-pdf
November 16, 2022 - Electronic diagnostic support in emergency physician
triage: qualitative study with thematic analysis of
interviews.
November 16, 2022
Sibbald M, Abdulla B, Keuhl A, et al. Electronic diagnostic support in emergency physician triage:
qualitative study with thematic analysis of interviews. JMIR Hum Factors. 2022;9(…
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psnet.ahrq.gov/node/35724/psn-pdf
May 26, 2010 - A prospective study of patient safety in the operating
room.
May 26, 2010
Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room.
Surgery. 2006;139(2):159-173.
https://psnet.ahrq.gov/issue/prospective-study-patient-safety-operating-room
This study used a multidisci…
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psnet.ahrq.gov/node/48173/psn-pdf
August 28, 2019 - Does learning from mistakes have to be painful? Analysis
of 5 years' experience from the Leeds radiology
educational cases meetings identifies common repetitive
reporting errors and suggests acknowledging and
celebrating excellence (ACE) as a more positive way of
teaching the same lessons.
August 28, 2019
Koo A,…
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psnet.ahrq.gov/node/46271/psn-pdf
January 30, 2018 - Debiasing health-related judgments and decision making:
a systematic review.
January 30, 2018
Ludolph R, Schulz PJ. Debiasing Health-Related Judgments and Decision Making: A Systematic Review.
Med Decis Making. 2018;38(1):3-13. doi:10.1177/0272989X17716672.
https://psnet.ahrq.gov/issue/debiasing-health-related-jud…
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psnet.ahrq.gov/node/36856/psn-pdf
August 31, 2011 - Hospital workload and adverse events.
August 31, 2011
Weissman JS, Rothschild JM, Bendavid E, et al. Hospital workload and adverse events. Med Care.
2007;45(5):448-55.
https://psnet.ahrq.gov/issue/hospital-workload-and-adverse-events
Past research suggests a relationship between nursing workload and quality of car…
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psnet.ahrq.gov/node/47467/psn-pdf
January 21, 2019 - Application of electronic trigger tools to identify targets
for improving diagnostic safety.
January 21, 2019
Murphy DR, Meyer AN, Sittig DF, et al. Application of electronic trigger tools to identify targets for improving
diagnostic safety. BMJ Qual Saf. 2019;28(2):151-159. doi:10.1136/bmjqs-2018-008086.
https://…
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psnet.ahrq.gov/node/47579/psn-pdf
December 12, 2018 - A prescription for enhancing electronic prescribing
safety.
December 12, 2018
Schiff G, Mirica MM, Dhavle AA, et al. A Prescription For Enhancing Electronic Prescribing Safety. Health
Aff (Millwood). 2018;37(11):1877-1883. doi:10.1377/hlthaff.2018.0725.
https://psnet.ahrq.gov/issue/prescription-enhancing-electroni…
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psnet.ahrq.gov/periodic-issue/periodic-issue-295
June 30, 2021 - anesthetist suggested use of video-laryngoscopy equipment, but the attending anesthesiologist rejected the suggestion
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psnet.ahrq.gov/periodic-issue/periodic-issue-296
June 30, 2021 - anesthetist suggested use of video-laryngoscopy equipment, but the attending anesthesiologist rejected the suggestion
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psnet.ahrq.gov/node/38534/psn-pdf
January 31, 2013 - Health care information technology vendors' "hold
harmless" clause: implications for patients and clinicians.
January 31, 2013
Koppel R, Kreda D. Health care information technology vendors' "hold harmless" clause: implications for
patients and clinicians. JAMA. 2009;301(12):1276-8. doi:10.1001/jama.2009.398.
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