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psnet.ahrq.gov/node/844059/psn-pdf
February 08, 2023 - Misdiagnosis in the emergency department: time for a
system solution.
February 8, 2023
Edlow JA, Pronovost PJ. Misdiagnosis in the emergency department: time for a system solution. JAMA.
2023;329(8):631-632. doi:10.1001/jama.2023.0577.
https://psnet.ahrq.gov/issue/misdiagnosis-emergency-department-time-system-solu…
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psnet.ahrq.gov/node/836792/psn-pdf
March 23, 2022 - Remote patient monitoring during COVID-19: an
unexpected patient safety benefit.
March 23, 2022
Pronovost PJ, Cole MD, Hughes RM. Remote patient monitoring during COVID-19: an unexpected patient
safety benefit. JAMA. 2022;327(12):1125-1126. doi:10.1001/jama.2022.2040.
https://psnet.ahrq.gov/issue/remote-patient-mo…
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psnet.ahrq.gov/node/47737/psn-pdf
March 06, 2019 - Quality improvement and safety in pediatric emergency
medicine.
March 6, 2019
Ku BC, Chamberlain JM, Shaw KN. Quality Improvement and Safety in Pediatric Emergency Medicine.
Pediatr Clin North Am. 2018;65(6):1269-1281. doi:10.1016/j.pcl.2018.07.010.
https://psnet.ahrq.gov/issue/quality-improvement-and-safety-pedia…
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psnet.ahrq.gov/node/44465/psn-pdf
November 20, 2015 - Why even good physicians do not wash their hands.
November 20, 2015
Redelmeier DA, Shafir E. Why even good physicians do not wash their hands. BMJ Qual Saf.
2015;24(12):744-7. doi:10.1136/bmjqs-2015-004319.
https://psnet.ahrq.gov/issue/why-even-good-physicians-do-not-wash-their-hands
Insufficient hand hygiene comp…
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psnet.ahrq.gov/node/866073/psn-pdf
June 05, 2024 - Improving communication of diagnostic uncertainty to
families of hospitalized children.
June 5, 2024
Young EE, Kane J, Timmons K, et al. Improving communication of diagnostic uncertainty to families of
hospitalized children. Diagnosis (Berl). 2024;11(2):186-191. doi:10.1515/dx-2023-0088.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/46489/psn-pdf
January 01, 2021 - Intervening in interruptions: what exactly is the risk we
are trying to manage?
October 11, 2017
Gao J, Rae AJ, Dekker SWA. Intervening in Interruptions: What Exactly Is the Risk We Are Trying to
Manage? J Patient Saf. 2021;17(7):e684-e688. doi:10.1097/PTS.0000000000000429.
https://psnet.ahrq.gov/issue/intervening…
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psnet.ahrq.gov/node/44853/psn-pdf
February 03, 2016 - Aviation and healthcare: a comparative review with
implications for patient safety.
February 3, 2016
Kapur N, Parand A, Soukup T, et al. Aviation and healthcare: a comparative review with implications for
patient safety. JRSM Open. 2016;7(1):2054270415616548. doi:10.1177/2054270415616548.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/847056/psn-pdf
April 05, 2023 - Early diagnosis of cancer: systems approach to support
clinicians in primary care.
April 5, 2023
Black GB, Lyratzopoulos G, Vincent CA, et al. Early diagnosis of cancer: systems approach to support
clinicians in primary care. BMJ. 2023;380:e071225. doi:10.1136/bmj-2022-071225.
https://psnet.ahrq.gov/issue/early-di…
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psnet.ahrq.gov/node/838078/psn-pdf
September 14, 2022 - Patient safety issues from information overload in
electronic medical records.
September 14, 2022
Nijor S, Rallis G, Lad N, et al. Patient safety issues from information overload in electronic medical records.
J Patient Saf. 2022;18(6):e999-e1003. doi:10.1097/pts.0000000000001002.
https://psnet.ahrq.gov/issue/pati…
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psnet.ahrq.gov/node/47222/psn-pdf
October 03, 2018 - Decision support tools, systems, and artificial intelligence
in cardiac imaging.
October 3, 2018
Massalha S, Clarkin O, Thornhill R, et al. Decision Support Tools, Systems, and Artificial Intelligence in
Cardiac Imaging. Can J Cardiol. 2018;34(7):827-838. doi:10.1016/j.cjca.2018.04.032.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/73683/psn-pdf
September 08, 2021 - Why and how to approach user experience in safety-
critical domains: the example of health care.
September 8, 2021
Grundgeiger T, Hurtienne J, Happel O. Why and how to approach user experience in safety-critical
domains: the example of health care. Hum Factors. 2020;63(5):821-832. doi:10.1177/0018720819887575.
htt…
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psnet.ahrq.gov/node/841155/psn-pdf
February 02, 2020 - Understanding unwarranted variation in clinical practice:
a focus on network effects, reflective medicine and
learning health systems.
February 2, 2020
Atsma F, Elwyn G, Westert GP. Understanding unwarranted variation in clinical practice: a focus on
network effects, reflective medicine and learning health systems…
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psnet.ahrq.gov/node/46149/psn-pdf
June 28, 2017 - Clinical outcomes associated with medication regimen
complexity in older people: a systematic review.
June 28, 2017
Wimmer BC, Cross AJ, Jokanovic N, et al. Clinical Outcomes Associated with Medication Regimen
Complexity in Older People: A Systematic Review. J Am Geriatr Soc. 2016;65(4):747-753.
doi:10.1111/jgs.14…
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psnet.ahrq.gov/node/44739/psn-pdf
January 13, 2016 - Missed opportunities for diagnosis: lessons learned from
diagnostic errors in primary care.
January 13, 2016
Goyder CR, Jones CHD, Heneghan CJ, et al. Missed opportunities for diagnosis: lessons learned from
diagnostic errors in primary care. Br J Gen Pract. 2015;65(641):e838-e844. doi:10.3399/bjgp15X687889.
https…
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psnet.ahrq.gov/node/48189/psn-pdf
August 14, 2019 - Professionalism lapses and adverse childhood
experiences: reflections from the island of last resort.
August 14, 2019
Williams BW. Professionalism Lapses and Adverse Childhood Experiences: Reflections From the Island of
Last Resort. Acad Med. 2019;94(8):1081-1083. doi:10.1097/ACM.0000000000002793.
https://psnet.ah…
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psnet.ahrq.gov/node/45301/psn-pdf
April 22, 2017 - Reviewing deaths in British and US hospitals: a study of
two scales for assessing preventability.
April 22, 2017
Manaseki-Holland S, Lilford RJ, Bishop JRB, et al. Reviewing deaths in British and US hospitals: a study of
two scales for assessing preventability. BMJ Qual Saf. 2017;26(5):408-416. doi:10.1136/bmjqs-20…
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psnet.ahrq.gov/node/837777/psn-pdf
August 03, 2020 - To err is human, unless you are a healthcare provider.
August 3, 2020
Zajicek J. Belmont Health Law J. 2020;4:79-135.
https://psnet.ahrq.gov/issue/err-human-unless-you-are-healthcare-provider
Intent to harm is a primary factor in the criminalization of patient injury. This article discusses the increase
of crimina…
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psnet.ahrq.gov/node/72481/psn-pdf
November 18, 2020 - Computer-based simulation to reduce EHR-related
chemotherapy ordering errors.
November 18, 2020
Wyatt KD, Freedman EB, Arteaga GM, et al. Computer?based simulation to reduce EHR?related
chemotherapy ordering errors. Cancer Med. 2020;9(23):8844-8851. doi:10.1002/cam4.3496.
https://psnet.ahrq.gov/issue/computer-base…
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psnet.ahrq.gov/node/43836/psn-pdf
March 11, 2015 - Hospital organisation, management, and structure for
prevention of health-care-associated infection: a
systematic review and expert consensus.
March 11, 2015
Zingg W, Holmes A, Dettenkofer M, et al. Hospital organisation, management, and structure for prevention
of health-care-associated infection: a systematic re…
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psnet.ahrq.gov/node/846148/psn-pdf
March 15, 2023 - Near-miss events detected using the emergency
department trigger tool.
March 15, 2023
Griffey RT, Schneider RM, Todorov AA. Near-miss events detected using the emergency department
trigger tool. J Patient Saf. 2023;19(2):59-66. doi:10.1097/pts.0000000000001092.
https://psnet.ahrq.gov/issue/near-miss-events-detecte…