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psnet.ahrq.gov/node/35776/psn-pdf
March 10, 2011 - A systematic review of the literature on multidisciplinary
rounds to design information technology.
March 10, 2011
Gurses AP, Xiao Y. A systematic review of the literature on multidisciplinary rounds to design information
technology. J Am Med Inform Assoc. 2006;13(3):267-76.
https://psnet.ahrq.gov/issue/systematic…
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psnet.ahrq.gov/node/34928/psn-pdf
February 25, 2009 - Understanding safer practices in health care: a prologue
for the role of indicators.
February 25, 2009
Kazandjian VA, Wicker K, Ogunbo S, et al. Understanding safer practices in health care: a prologue for the
role of indicators. J Eval Clin Pract. 2005;11(2):161-70.
https://psnet.ahrq.gov/issue/understanding-safe…
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psnet.ahrq.gov/node/50878/psn-pdf
February 05, 2020 - The role of racism as a core patient safety issue.
February 5, 2020
Feeley D, Torres T. The role of racism as a core patient safety issue. Healthcare Executive. 2020;35(1):58-
61.
https://psnet.ahrq.gov/issue/role-racism-core-patient-safety-issue
A variety of biases can reduce the effectiveness and safety of care.…
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psnet.ahrq.gov/node/38297/psn-pdf
May 21, 2014 - Assessment of the AHRQ Patient Safety Initiative: Focus
on Implementation and Dissemination Evaluation Report
III.
May 21, 2014
Farley DO, Damberg CL, Ridgely MS, et al. Santa Monica, CA: RAND Corporation; 2007. ISBN:
9780833042170
https://psnet.ahrq.gov/issue/assessment-ahrq-patient-safety-initiative-focus-imple…
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psnet.ahrq.gov/node/36241/psn-pdf
October 21, 2010 - 'Clean Care is Safer Care': the Global Patient Safety
Challenge 2005-2006.
October 21, 2010
Pittet D, Allegranzi B, Storr J, et al. 'Clean Care is Safer Care': the Global Patient Safety Challenge 2005-
2006. Int J Infect Dis. 2006;10(6):419-24.
https://psnet.ahrq.gov/issue/clean-care-safer-care-global-patient-safe…
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psnet.ahrq.gov/node/46495/psn-pdf
December 13, 2017 - Wrong-site surgery.
December 13, 2017
Engelhardt KE, Barnard C, Bilimoria KY. Wrong-Site Surgery. JAMA. 2017;318(20):2033-2034.
doi:10.1001/jama.2017.17177.
https://psnet.ahrq.gov/issue/wrong-site-surgery-1
This commentary describes a case of wrong-site surgery, an erroneous breast biopsy, and the resulting
discl…
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psnet.ahrq.gov/node/866528/psn-pdf
August 14, 2024 - First with Kids: Medication Errors.
August 14, 2024
First L. NBC5. First with Kids: Medication Errors. August 1, 2024.
https://psnet.ahrq.gov/issue/first-kids-medication-errors
Medication mistakes involving children are common. This news segment provides suggestions for parents
to help improve the safety of medica…
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psnet.ahrq.gov/node/43577/psn-pdf
October 01, 2014 - The State of VA Health Care.
October 1, 2014
Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9,
2014).
https://psnet.ahrq.gov/issue/state-va-health-care
In this hearing Veterans Affairs leadership provide an update on the current investigation into data and
scheduling…
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psnet.ahrq.gov/node/35595/psn-pdf
January 04, 2009 - Patient Safety: Achieving a New Standard of Care.
January 4, 2009
Institute of Medicine (US) Committee on Data Standards for Patient Safety, Aspden P, Corrigan JM,
Wolcott J, Erickson SM, eds. Washington (DC): National Academies Press (US); 2004.
https://psnet.ahrq.gov/issue/patient-safety-achieving-new-standa…
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psnet.ahrq.gov/node/45443/psn-pdf
September 07, 2016 - Making health care safer. Think sepsis. Time matters.
September 7, 2016
CDC; Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/making-health-care-safer-think-sepsis-time-matters
Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of
infographics spotl…
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psnet.ahrq.gov/node/37568/psn-pdf
February 03, 2011 - Survival from in-hospital cardiac arrest during nights and
weekends.
February 3, 2011
Peberdy MA, Ornato JP, Larkin L, et al. Survival from in-hospital cardiac arrest during nights and
weekends. JAMA. 2008;299(7):785-92. doi:10.1001/jama.299.7.785.
https://psnet.ahrq.gov/issue/survival-hospital-cardiac-arrest-duri…
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psnet.ahrq.gov/node/35614/psn-pdf
March 10, 2011 - Overriding of drug safety alerts in computerized
physician order entry.
March 10, 2011
van der Sijs H, Aarts J, Vulto A, et al. Overriding of drug safety alerts in computerized physician order
entry. J Am Med Inform Assoc. 2006;13(2):138-47.
https://psnet.ahrq.gov/issue/overriding-drug-safety-alerts-computerized-p…
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psnet.ahrq.gov/node/40775/psn-pdf
September 14, 2011 - Ambulatory surgery facilities: a comprehensive review of
medication error reports in Pennsylvania.
September 14, 2011
Grissinger M, Dabliz R. Pa Patient Saf Advis 2011 Sep;8(3):85-93.
https://psnet.ahrq.gov/issue/ambulatory-surgery-facilities-comprehensive-review-medication-error-reports-
pennsylvania
Anal…
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psnet.ahrq.gov/node/47981/psn-pdf
May 15, 2019 - Systematic error and cognitive bias in obstetric
ultrasound.
May 15, 2019
Sotiriadis A, Odibo AO. Systematic error and cognitive bias in obstetric ultrasound. Ultrasound Obstet
Gynecol. 2019;53(4):431-435. doi:10.1002/uog.20232.
https://psnet.ahrq.gov/issue/systematic-error-and-cognitive-bias-obstetric-ultrasound
…
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psnet.ahrq.gov/node/47621/psn-pdf
May 11, 2019 - 2018 update on pediatric medical overuse: a review.
May 11, 2019
Coon ER, Quinonez RA, Morgan DJ, et al. 2018 Update on Pediatric Medical Overuse: A Review. JAMA
Pediatr. 2019;173(4):379-384. doi:10.1001/jamapediatrics.2018.5550.
https://psnet.ahrq.gov/issue/2018-update-pediatric-medical-overuse-review
Overuse of …
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psnet.ahrq.gov/node/36564/psn-pdf
January 12, 2011 - Preventing medication errors in hospitals through a
systems approach and technological innovation: a
prescription for 2010.
January 12, 2011
Crane J, Crane FG. Preventing medication errors in hospitals through a systems approach and
technological innovation: a prescription for 2010. Hosp Top. 2006;84(4):3-8.
http…
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psnet.ahrq.gov/node/43732/psn-pdf
January 07, 2015 - Rethinking diagnostic delay in cancer: how difficult is the
diagnosis?
January 7, 2015
Lyratzopoulos G, Wardle J, Rubin G. Rethinking diagnostic delay in cancer: how difficult is the diagnosis?
BMJ. 2014;349:g7400. doi:10.1136/bmj.g7400.
https://psnet.ahrq.gov/issue/rethinking-diagnostic-delay-cancer-how-difficult…
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psnet.ahrq.gov/node/35113/psn-pdf
April 06, 2011 - Medication errors in intravenous drug preparation and
administration: a multicentre audit in the UK, Germany
and France.
April 6, 2011
Cousins DH, Sabatier B, Begue D, et al. Medication errors in intravenous drug preparation and
administration: a multicentre audit in the UK, Germany and France. Qual Saf Health Car…
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psnet.ahrq.gov/node/35846/psn-pdf
July 22, 2010 - Why worry? Worry, risk perceptions, and willingness to
act to reduce medical errors.
July 22, 2010
Peters E, Slovic P, Hibbard JH, et al. Why worry? Worry, risk perceptions, and willingness to act to reduce
medical errors. Health Psychology. 2006;25(2). doi:10.1037/0278-6133.25.2.144.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/40374/psn-pdf
April 13, 2011 - Better off not knowing: improving clinical care by limiting
physician access to unsolicited diagnostic information.
April 13, 2011
Volk ML, Ubel PA. Better off not knowing: improving clinical care by limiting physician access to unsolicited
diagnostic information. Arch Intern Med. 2011;171(6):487-8. doi:10.1001/arc…