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psnet.ahrq.gov/issue/when-good-doctors-go-bad-systems-problem
November 02, 2014 - Commentary
When good doctors go bad: a systems problem. … When good doctors go bad: a systems problem. Ann Surg. 2006;244(5):649-652. … When good doctors go bad: a systems problem. Ann Surg. 2006;244(5):649-652.
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psnet.ahrq.gov/issue/healthcare-systems-ergonomics-and-patient-safety-triennial-conference
February 10, 2015 - Meeting/Conference
Healthcare Systems Ergonomics and Patient Safety Triennial Conference … Citation Text:
Healthcare Systems Ergonomics and Patient Safety Triennial Conference. … Copy URL
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Healthcare Systems
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psnet.ahrq.gov/issue/systems-analysis-critical-incidents-london-protocol
April 06, 2016 - Book/Report
Systems Analysis of Critical Incidents: the London Protocol. … Citation Text:
Systems Analysis of Critical Incidents: the London Protocol. … Linkedin
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Systems … May 24, 2015
Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews
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psnet.ahrq.gov/issue/sustained-user-engagement-health-information-technology-long-road-implementation-system
December 21, 2022 - implementation to system optimization of computerized physician order entry and clinical decision support systems … Implementation to System Optimization of Computerized Physician Order Entry and Clinical Decision Support Systems … December 21, 2022
Workarounds to hospital electronic prescribing systems: a qualitative … of hospital health information technologies: a qualitative study of hospital electronic prescribing systems … January 7, 2015
Decision support for sensible dosing in electronic prescribing systems
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psnet.ahrq.gov/issue/health-systems-and-hospitals-pursuit-high-reliability
October 23, 2019 - Newspaper/Magazine Article
Health systems and hospitals in pursuit of high reliability … Citation Text:
Health systems and hospitals in pursuit of high reliability. Cheney C. … Linkedin
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Health systems
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psnet.ahrq.gov/issue/improving-rapid-response-systems-progress-issues-and-future-directions
January 26, 2022 - Meeting/Conference Proceedings
Improving rapid response systems: progress, issues … Improving rapid response systems: progress, issues, and future directions. … Improving rapid response systems: progress, issues, and future directions. … April 18, 2018
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Rapid response systems … January 22, 2017
The growth of rapid response systems.
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psnet.ahrq.gov/issue/rapid-response-systems-prospective-study-response-times
November 16, 2022 - Study
Rapid response systems: a prospective study of response times. … Rapid response systems: a prospective study of response times. … Rapid response systems: a prospective study of response times. … June 12, 2013
High performance teamwork training and systems redesign in outpatient oncology … October 12, 2012
Early warning systems: the next level of rapid response.
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psnet.ahrq.gov/issue/systematic-review-clinical-decision-support-systems-clinical-oncology-practice
July 19, 2023 - Review
A systematic review of clinical decision support systems for clinical oncology … A Systematic Review of Clinical Decision Support Systems for Clinical Oncology Practice. … A Systematic Review of Clinical Decision Support Systems for Clinical Oncology Practice. … May 17, 2023
Electronic prescribing systems in hospitals to improve medication safety … April 12, 2019
Artificial intelligence systems for complex decision-making in acute care
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psnet.ahrq.gov/issue/fifth-discipline-art-practice-learning-organization-revised-updated-edition
May 12, 2010 - ’s seminal and oft-referenced book outlines five competencies that support a learning organization: systems … He introduces the concept of systems thinking and describes how systems often conspire to create their … Senge’s influence can be seen in much of the conceptual “systems thinking” literature in patient safety … December 16, 2020
A systems analysis of work-related violence in hospitals: stakeholders … February 22, 2023
Toward the translation of systems thinking methods in patient safety
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psnet.ahrq.gov/issue/relationship-between-hospital-systems-load-and-patient-harm
November 12, 2008 - Study
The relationship between hospital systems load and patient harm. … The relationship between hospital systems load and patient harm. … The relationship between hospital systems load and patient harm. … Analysis of variations in the display of drug names in computerized prescriber-order-entry systems
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psnet.ahrq.gov/issue/relationship-between-medication-event-rates-and-leapfrog-computerized-physician-order-entry
November 26, 2014 - As more hospitals begin to implement computerized provider order entry (CPOE) systems, rigorously evaluating … this study reports on the validation of a tool developed by Leapfrog for assessing the ability of CPOE systems … Prior simulation research has shown that many commercial systems fail to detect even potentially serious … errors, and this study provides reassurance that CPOE systems that pass the Leapfrog evaluation are … September 25, 2011
Evaluating clinical decision support systems: monitoring CPOE order
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psnet.ahrq.gov/issue/clinical-ict-systems-victorian-public-health-sector
September 08, 2010 - Book/Report
Clinical ICT Systems in the Victorian Public Health Sector. … Citation Text:
Clinical ICT Systems in the Victorian Public Health Sector. Doyle J. … Copy URL
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Clinical ICT Systems … medication errors that are new or likely to occur more frequently with electronic medication management systems … February 6, 2019
Accurate measurement in California's safety-net health systems has gaps
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psnet.ahrq.gov/issue/airway-carts-systems-based-approach-airway-safety
July 21, 2010 - Study
Airway carts: a systems-based approach to airway safety.
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psnet.ahrq.gov/issue/relationship-between-systems-level-factors-and-hand-hygiene-adherence
September 28, 2011 - Study
Relationship between systems-level factors and hand hygiene adherence. … Relationship between systems-level factors and hand hygiene adherence. … Relationship between systems-level factors and hand hygiene adherence.
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psnet.ahrq.gov/issue/decision-support-sensible-dosing-electronic-prescribing-systems
February 23, 2011 - Study
Decision support for sensible dosing in electronic prescribing systems. … Decision support for sensible dosing in electronic prescribing systems. … Decision support for sensible dosing in electronic prescribing systems. … Tool for Improving Patient Safety
March 29, 2023
Electronic prescribing systems … implementing commercial computerized physician order entry and clinical decision support prescribing systems
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psnet.ahrq.gov/issue/practising-open-disclosure-clinical-incident-communication-and-systems-improvement
November 23, 2016 - Commentary
Practising open disclosure: clinical incident communication and systems … Practising Open Disclosure: clinical incident communication and systems improvement. … Practising Open Disclosure: clinical incident communication and systems improvement.
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psnet.ahrq.gov/node/60946/psn-pdf
September 23, 2020 - Systems thinking for managing COVID-19 in health care
systems: seven key messages. … Systems thinking for managing COVID-19 in health care systems: seven key
messages. … https://psnet.ahrq.gov/issue/systems-thinking-managing-covid-19-health-care-systems-seven-key-
messages … of
the systems awareness model (SAM) for managing the COVID-19 in health systems. … https://psnet.ahrq.gov/issue/systems-thinking-managing-covid-19-health-care-systems-seven-key-messages
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - Learning Health Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. … Learning Health Systems for Patient Safety. PSNet [internet]. 2025. … https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
Despite an observable decrease … Because of this, researchers are another important component of learning
health systems. … https://psnet.ahrq.gov//#13
https://psnet.ahrq.gov//#14
https://psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
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psnet.ahrq.gov/node/33609/psn-pdf
March 15, 2025 - Clinical Decision Support Systems
March 15, 2025
Clinical Decision Support Systems. … https://psnet.ahrq.gov/primer/clinical-decision-support-systems
PSNet primers are regularly reviewed … The promised benefits of health information technology rest in large part on the ability of these systems … as one of its criteria for certifying
electronic health record systems. … Clinical decision support systems address activities ranging from the selection of medications (e.g.,
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psnet.ahrq.gov/node/74208/psn-pdf
December 22, 2021 - Early warning systems and rapid response systems for
the prevention of patient deterioration on acute … Early warning systems and rapid response systems for
the prevention of patient deterioration on acute … https://psnet.ahrq.gov/issue/early-warning-systems-and-rapid-response-systems-prevention-patient-
deterioration-acute-adult … Rapid response systems (RRS) and early warning systems (EWS) are designed to detect patient
deterioration … https://psnet.ahrq.gov/issue/early-warning-systems-and-rapid-response-systems-prevention-patient-deterioration-acute-adult