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psnet.ahrq.gov/node/43390/psn-pdf
July 30, 2014 - Hazards tied to medical records rush.
July 30, 2014
Rowland C.
https://psnet.ahrq.gov/issue/hazards-tied-medical-records-rush
Government incentives have led to rapid development and adoption of electronic health records (EHRs).
This newspaper article examines some of the unintended consequences of implementing ele…
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psnet.ahrq.gov/node/48028/psn-pdf
August 28, 2019 - Error Reduction and Prevention in Surgical Pathology,
Second Edition.
August 28, 2019
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
https://psnet.ahrq.gov/issue/error-reduction-and-prevention-surgical-pathology-2nd-edition
Surgical specimen and laboratory process proble…
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psnet.ahrq.gov/node/44988/psn-pdf
September 20, 2016 - The promise of big data: improving patient safety and
nursing practice.
September 20, 2016
Linnen D. The promise of big data: Improving patient safety and nursing practice. Nursing (Brux).
2016;46(5):28-34; quiz 34-5. doi:10.1097/01.NURSE.0000482256.71143.09.
https://psnet.ahrq.gov/issue/promise-big-data-improving…
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psnet.ahrq.gov/node/48005/psn-pdf
May 08, 2019 - Why your doctor's white coat can be a threat to your
health.
May 8, 2019
Haun N, Hooper-Lane C, Safdar N. Healthcare Personnel Attire and Devices as Fomites: A Systematic
Review. Infect Control Hosp Epidemiol. 2016;37(11):1367-1373.
https://psnet.ahrq.gov/issue/why-your-doctors-white-coat-can-be-threat-your-health…
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psnet.ahrq.gov/node/40097/psn-pdf
January 19, 2011 - Use of an electronic information system to identify
adverse events resulting in an emergency department
visit.
January 19, 2011
Ackroyd-Stolarz S, MacKinnon NJ, Zed PJ, et al. Use of an electronic information system to identify
adverse events resulting in an emergency department visit. Qual Saf Health Care. 2010;1…
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psnet.ahrq.gov/node/45281/psn-pdf
September 01, 2016 - Screen flashes and pop-up reminders: 'alert fatigue'
spreads through medicine.
September 1, 2016
Luthra S. Kaiser Health News. June 15, 2016.
https://psnet.ahrq.gov/issue/screen-flashes-and-pop-reminders-alert-fatigue-spreads-through-medicine
Alert fatigue is known to contribute to medical error. This news article…
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psnet.ahrq.gov/node/41459/psn-pdf
August 02, 2012 - The use of simulation in healthcare: from systems issues,
to team building, to task training, to education and high
stakes examinations.
August 2, 2012
Orledge J, Phillips WJ, Murray B, et al. The use of simulation in healthcare: from systems issues, to team
building, to task training, to education and high stakes…
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psnet.ahrq.gov/node/40690/psn-pdf
August 17, 2011 - Designing a safer process to prevent retained surgical
sponges: a healthcare failure mode and effect analysis.
August 17, 2011
Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare
failure mode and effect analysis. AORN J. 2011;94(2):132-41. doi:10.1016/j.aorn.2010.09.…
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psnet.ahrq.gov/node/44386/psn-pdf
August 12, 2015 - Using simulation to improve systems.
August 12, 2015
Lundberg PW, Korndorffer JR. Using Simulation to Improve Systems. Surg Clin North Am. 2015;95(4):885-
92. doi:10.1016/j.suc.2015.04.007.
https://psnet.ahrq.gov/issue/using-simulation-improve-systems
Safety approaches from aviation that can be applied to health c…
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psnet.ahrq.gov/node/44309/psn-pdf
June 14, 2019 - Provider and patient perceptions of an external
medication history function.
June 14, 2019
Wolver SE, Stultz JS, Aggarwal A, et al. Provider and Patient Perceptions of an External Medication History
Function. J Patient Saf. 2018;14(4):234-240. doi:10.1097/PTS.0000000000000197.
https://psnet.ahrq.gov/issue/provider…
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psnet.ahrq.gov/node/837140/psn-pdf
May 18, 2022 - Nursing surveillance: a concept analysis
May 18, 2022
Halverson CC, Scott Tilley D. Nursing surveillance: a concept analysis. Nurs Forum. 2022;57(3):454-460.
doi:10.1111/nuf.12702.
https://psnet.ahrq.gov/issue/nursing-surveillance-concept-analysis
Nursing surveillance is an intervention for maintaining patient saf…
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psnet.ahrq.gov/node/852803/psn-pdf
August 23, 2023 - Sentinel Event Alert 67: Preserving Patient Safety After a
Cyberattack.
August 23, 2023
Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. Jt Comm J Qual Patient Saf.
2023;49(12):724-729. doi:10.1016/j.jcjq.2023.07.006.
https://psnet.ahrq.gov/issue/sentinel-event-alert-67-preserving-patient-sa…
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psnet.ahrq.gov/node/47408/psn-pdf
September 19, 2018 - Ways to Improve Electronic Health Record Safety.
September 19, 2018
Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018.
https://psnet.ahrq.gov/issue/ways-improve-electronic-health-record-safety
Electronic health records both contribute to and detract from safe care. This…
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psnet.ahrq.gov/node/47051/psn-pdf
October 18, 2018 - Errors and discrepancies in the administration of
intravenous infusions: a mixed methods multihospital
observational study.
October 18, 2018
Lyons I, Furniss D, Blandford A, et al. Errors and discrepancies in the administration of intravenous
infusions: a mixed methods multihospital observational study. BMJ Qual S…
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psnet.ahrq.gov/node/38996/psn-pdf
March 04, 2011 - Overcoming barriers to the implementation of a pharmacy
bar code scanning system for medication dispensing: a
case study.
March 4, 2011
Nanji KC, Cina J, Patel N, et al. Overcoming barriers to the implementation of a pharmacy bar code
scanning system for medication dispensing: a case study. J Am Med Inform Assoc. …
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psnet.ahrq.gov/node/41400/psn-pdf
January 01, 2013 - Conducting an efficient proactive risk assessment prior to
CPOE implementation in an intensive care unit.
December 12, 2012
Hundt AS, Adams JA, Schmid A, et al. Conducting an efficient proactive risk assessment prior to CPOE
implementation in an intensive care unit. Int J Med Inform. 2013;82(1):25-38.
doi:10.1016/…
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psnet.ahrq.gov/node/46398/psn-pdf
June 25, 2018 - Challenges in health care simulation: are we learning
anything new?
June 25, 2018
Henriksen K, Rodrick D, Grace EN, et al. Challenges in Health Care Simulation: Are We Learning Anything
New? Acad Med. 2018;93(5):705-708. doi:10.1097/ACM.0000000000001891.
https://psnet.ahrq.gov/issue/challenges-health-care-simulati…
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psnet.ahrq.gov/node/838623/psn-pdf
October 19, 2022 - Resident and nurse perspectives on the use of secure
text messaging systems.
October 19, 2022
Aziz S, Barber J, Singh A, et al. Resident and nurse perspectives on the use of secure text messaging
systems. J Hosp Med. 2022;17(11):880-887. doi:10.1002/jhm.12953.
https://psnet.ahrq.gov/issue/resident-and-nurse-perspe…
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psnet.ahrq.gov/node/45888/psn-pdf
December 19, 2017 - A work systems analysis approach to understanding
fatigue in hospital nurses.
December 19, 2017
Steege LM, Pasupathy KS, Drake DA. A work systems analysis approach to understanding fatigue in
hospital nurses. Ergonomics. 2017;61(1):148-161. doi:10.1080/00140139.2017.1280186.
https://psnet.ahrq.gov/issue/work-syste…
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psnet.ahrq.gov/node/46931/psn-pdf
January 15, 2019 - Strategies for optimizing OR drug safety.
January 15, 2019
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
https://psnet.ahrq.gov/issue/strategies-optimizing-or-drug-safety
Perioperative adverse drug events are common and understudied. Reporting on the complexity of
medication administration durin…