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psnet.ahrq.gov/node/38000/psn-pdf
August 03, 2009 - The competitive imperative of learning.
August 3, 2009
Edmondson A. The competitive imperative of learning. Harv Bus Rev. 2008;86(7-8):60-7, 160.
https://psnet.ahrq.gov/issue/competitive-imperative-learning
This article draws on experience analyzing team behavior in hospitals to discuss how learning processes
can …
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psnet.ahrq.gov/node/48041/psn-pdf
July 10, 2019 - Accuracy of computer-aided diagnosis of melanoma: a
meta-analysis.
July 10, 2019
Dick V, Sinz C, Mittlböck M, et al. Accuracy of Computer-Aided Diagnosis of Melanoma. JAMA Dermatol.
2019;155(11):1291-1299. doi:10.1001/jamadermatol.2019.1375.
https://psnet.ahrq.gov/issue/accuracy-computer-aided-diagnosis-melanoma-m…
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psnet.ahrq.gov/node/866247/psn-pdf
July 10, 2024 - Analysis of critical incident reports using natural
language processing.
July 10, 2024
Denecke K, Paula H. Analysis of critical incident reports using natural language processing. Stud Health
Technol Inform. 2024;313:1-6. doi:10.3233/shti240002.
https://psnet.ahrq.gov/issue/analysis-critical-incident-reports-using…
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psnet.ahrq.gov/node/38752/psn-pdf
September 24, 2016 - Interruptions and geographic challenges to nurses'
cognitive workload.
September 24, 2016
Redding DA, Robinson S. Interruptions and geographic challenges to nurses' cognitive workload. J Nurs
Care Qual. 2009;24(3):194-200; quiz 201-202. doi:10.1097/01.NCQ.0000356907.95076.31.
https://psnet.ahrq.gov/issue/interrupt…
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psnet.ahrq.gov/node/35020/psn-pdf
June 22, 2009 - Surgical skill is predicted by the ability to detect errors.
June 22, 2009
Bann S, Khan M, Datta V, et al. Surgical skill is predicted by the ability to detect errors. Am J Surg.
2005;189(4):412-5.
https://psnet.ahrq.gov/issue/surgical-skill-predicted-ability-detect-errors
The investigators observed surgeons parti…
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psnet.ahrq.gov/node/42799/psn-pdf
December 04, 2013 - All can be lost: the risk of putting our knowledge in the
hands of machines.
December 4, 2013
Carr N. The Atlantic. November 2013.
https://psnet.ahrq.gov/issue/all-can-be-lost-risk-putting-our-knowledge-hands-machines
Increasingly, computerized systems are performing more complex tasks in high-risk industries like…
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psnet.ahrq.gov/node/848383/psn-pdf
May 03, 2023 - Burnout in Primary Care: Assessing and Addressing It in
Your Practice.
May 3, 2023
Gerteis J, Booker C, Brach C, et al. Rockville, MD: Agency for Healthcare Research and Quality;
February 2023. AHRQ Publication No. 23-0025.
https://psnet.ahrq.gov/issue/burnout-primary-care-assessing-and-addressing-it-your-pr…
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psnet.ahrq.gov/node/47775/psn-pdf
April 03, 2019 - Reducing diagnostic errors worldwide through diagnostic
management teams.
April 3, 2019
Verna R, Velazquez AB, Laposata M. Reducing Diagnostic Errors Worldwide Through Diagnostic
Management Teams. Ann Lab Med. 2019;39(2):121-124. doi:10.3343/alm.2019.39.2.121.
https://psnet.ahrq.gov/issue/reducing-diagnostic-error…
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psnet.ahrq.gov/node/33602/psn-pdf
March 15, 2025 - fatigued or placed in situations in which they lack adequate training or supervision to
perform a task
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psnet.ahrq.gov/node/33580/psn-pdf
April 01, 2022 - Human
factors engineering principles hold that when an individual is attempting a complex task, such … hospitalized patient, the work environment should be as conducive as
possible to carrying out that task
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psnet.ahrq.gov/node/49479/psn-pdf
April 01, 2005 - for specific
problems, the technique scales poorly, since it is impractical to implement on paper task-specific … support, which alerts the user about a potential issue without
diverting him or her from the current task
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psnet.ahrq.gov/node/863215/psn-pdf
February 28, 2024 - Learning from non-routine events and teamwork in
intensive care units: challenges and opportunities.
February 28, 2024
Gong Y, Chen Y. Learning from non-routine events and teamwork in intensive care units: challenges and
opportunities. Stud Health Technol Inform. 2024;310:324-328. doi:10.3233/shti230980.
https://p…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
September 01, 2006 - Spotlight Case September 2006
Spotlight Case September 2006
Triple Handoff
Source and Credits
This presentation is based on the September 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Arpana Vidyarthi, MD, UCSF Sc…
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psnet.ahrq.gov/node/60840/psn-pdf
August 26, 2020 - Role of artificial intelligence in patient safety outcomes:
systematic literature review.
August 26, 2020
Choudhury A, Asan O. Role of artificial intelligence in patient safety outcomes: systematic literature review.
JMIR Med Inform. 2020;8(7):e18599. doi:10.2196/18599.
https://psnet.ahrq.gov/issue/role-artificial…
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psnet.ahrq.gov/node/843325/psn-pdf
February 01, 2023 - Untenable expectations: nurses' work in the context of
medication administration, error, and the organization.
February 1, 2023
Hawkins SF, Morse JM. Untenable expectations: nurses' work in the context of medication administration,
error, and the organization. Glob Qual Nurs Res. 2022;9:233339362211317.
doi:10.117…
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psnet.ahrq.gov/node/73112/psn-pdf
April 07, 2021 - Smartphone distraction during nursing care: systematic
literature review.
April 7, 2021
Fiorinelli M, Di Mario S, Surace A, et al. Smartphone distraction during nursing care: systematic literature
review. Appl Nurs Res. 2021;58:151405. doi:10.1016/j.apnr.2021.151405.
https://psnet.ahrq.gov/issue/smartphone-distrac…
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psnet.ahrq.gov/node/40927/psn-pdf
November 16, 2011 - Hospitalization-associated disability: "She was probably
able to ambulate, but I'm not sure."
November 16, 2011
Covinsky KE, Pierluissi E, Johnston B. Hospitalization-associated disability: "She was probably able to
ambulate, but I'm not sure". JAMA. 2011;306(16):1782-93. doi:10.1001/jama.2011.1556.
https://psnet.…
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psnet.ahrq.gov/node/43152/psn-pdf
May 07, 2014 - The trainee's voice: recognising the importance of
preoperative briefings for surgical trainees.
May 7, 2014
Bethune R, Blencowe NS. The trainee's voice: recognising the importance of preoperative briefings for
surgical trainees. J Perioper Pract. 2014;24(3):56-58.
https://psnet.ahrq.gov/issue/trainees-voice-recog…
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psnet.ahrq.gov/node/856588/psn-pdf
November 29, 2023 - It depends who you ask: divergences in staff and external
stakeholder narratives about the causes of a healthcare
failure.
November 29, 2023
Hald EJ, Gillespie A, Reader TW. It depends who you ask: divergences in staff and external stakeholder
narratives about the causes of a healthcare failure. J Contingencies Cr…
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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…