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psnet.ahrq.gov/issue/institute-safe-medication-practices-and-poison-control-centers-collaborating-prevent
April 22, 2017 - Commentary
The Institute for Safe Medication Practices and poison control centers: collaborating to prevent medication errors and unintentional poisonings.
Citation Text:
Vaida AJ. The Institute for Safe Medication Practices and Poison Control Centers: Collaborating to Prevent Medication…
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psnet.ahrq.gov/issue/oncology-medication-safety-3d-status-report-2008
March 26, 2015 - Study
Oncology medication safety: a 3D status report 2008.
Citation Text:
Johnson PE, Chambers C, Vaida AJ. Oncology medication safety: a 3D status report 2008. J Oncol Pharm Pract. 2008;14(4):169-80. doi:10.1177/1078155208097634.
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psnet.ahrq.gov/issue/reducing-delay-diagnosis-multistage-recommendation-tracking
June 19, 2012 - Study
Reducing delay in diagnosis: multistage recommendation tracking.
Citation Text:
Wandtke B, Gallagher S. Reducing Delay in Diagnosis: Multistage Recommendation Tracking. AJR Am J Roentgenol. 2017;209(5):970-975. doi:10.2214/AJR.17.18332.
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psnet.ahrq.gov/issue/provider-and-patient-perceptions-external-medication-history-function
July 16, 2015 - Study
Provider and patient perceptions of an external medication history function.
Citation Text:
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.
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psnet.ahrq.gov/issue/tolerance-uncertainty-and-fears-making-mistakes-among-fifth-year-medical-students
December 09, 2020 - Study
Tolerance of uncertainty and fears of making mistakes among fifth-year medical students.
Citation Text:
Nevalainen M, Kuikka L, Sjoberg L, et al. Tolerance of uncertainty and fears of making mistakes among fifth-year medical students. Fam Med. 2012;44(4):240-6.
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psnet.ahrq.gov/issue/clinical-and-medicolegal-implications-radiology-results-communication
August 20, 2018 - Review
The clinical and medicolegal implications of radiology results communication.
Citation Text:
Aryal B, Khorsand DA, Dubinsky TJ. The Clinical and Medicolegal Implications of Radiology Results Communication. Curr Probl Diagn Radiol. 2018;47(5):287-289. doi:10.1067/j.cpradiol.2017.09…
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psnet.ahrq.gov/issue/why-it-so-hard-talk-about-overuse-pediatrics-and-why-it-matters
March 04, 2020 - Commentary
Why it is so hard to talk about overuse in pediatrics and why it matters.
Citation Text:
Ralston SL, Schroeder AR. Why It Is So Hard to Talk About Overuse in Pediatrics and Why It Matters. JAMA Pediatr. 2017;171(10):931-932. doi:10.1001/jamapediatrics.2017.2239.
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psnet.ahrq.gov/issue/lessons-learned-basic-evidence-based-advice-preventing-medication-errors-children
December 22, 2008 - Commentary
Lessons learned: basic evidence-based advice for preventing medication errors in children.
Citation Text:
Thomas DO. Lessons learned: basic evidence-based advice for preventing medication errors in children. Journal of emergency nursing: JEN : official publication of the Eme…
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psnet.ahrq.gov/issue/current-approaches-punitive-action-medication-errors-boards-pharmacy
May 26, 2011 - Study
Current approaches to punitive action for medication errors by boards of pharmacy.
Citation Text:
Holdsworth M, Wittstrom K, Yeitrakis T. Current approaches to punitive action for medication errors by boards of pharmacy. Ann Pharmacother. 2013;47(4):475-81. doi:10.1345/aph.1R668. …
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psnet.ahrq.gov/issue/patient-safety-problems-adolescent-medical-care
April 11, 2011 - Study
Patient safety problems in adolescent medical care.
Citation Text:
Woods D, Holl JL, Klein JD, et al. Patient safety problems in adolescent medical care. J Adolesc Health. 2006;38(1):5-12.
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psnet.ahrq.gov/issue/could-it-be-done-safely-pharmacists-views-safety-and-clinical-outcomes-introduction-advanced
October 22, 2014 - Study
Could it be done safely? Pharmacists views on safety and clinical outcomes from the introduction of an advanced role for technicians.
Citation Text:
Napier P, Norris P, Braund R. Could it be done safely? Pharmacists views on safety and clinical outcomes from the introduction of an …
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psnet.ahrq.gov/issue/review-significant-events-analysed-general-practice-implications-quality-and-safety-patient
October 29, 2008 - Study
A review of significant events analysed in general practice: implications for the quality and safety of patient care.
Citation Text:
McKay J, Bradley N, Lough M, et al. A review of significant events analysed in general practice: implications for the quality and safety of patient…
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psnet.ahrq.gov/issue/what-we-know-about-designing-effective-improvement-intervention-too-often-fail-put-practice
September 06, 2017 - Commentary
What we know about designing an effective improvement intervention (but too often fail to put into practice).
Citation Text:
Marshall M, de Silva D, Cruickshank L, et al. What we know about designing an effective improvement intervention (but too often fail to put into practic…
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psnet.ahrq.gov/issue/look-alike-sound-alike-drugs-review-include-look-alike-packaging-additional-safety-check
March 24, 2021 - Study
Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check.
Citation Text:
McCoy LK. Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check. Jt Comm J Qual Patient Saf. 2005;31(1):47-53.
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psnet.ahrq.gov/issue/intraoperative-communications-between-pathologists-and-surgeons-do-we-understand-each-other
June 28, 2023 - Study
Intraoperative communications between pathologists and surgeons: do we understand each other?
Citation Text:
Wiggett A, Fischer G. Intraoperative communications between pathologists and surgeons: do we understand each other? Arch Pathol Lab Med. 2023;147(8):933-939. doi:10.5858/arp…
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psnet.ahrq.gov/issue/incidence-and-severity-adverse-events-affecting-patients-after-discharge-hospital
March 11, 2019 - Study
Classic
The incidence and severity of adverse events affecting patients after discharge from the hospital.
Citation Text:
Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hos…
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psnet.ahrq.gov/issue/sleep-and-circadian-misalignment-hospitalist-review
July 15, 2020 - Review
Sleep and circadian misalignment for the hospitalist: a review.
Citation Text:
Schaefer EW, Williams M, Zee PC. Sleep and circadian misalignment for the hospitalist: a review. J Hosp Med. 2012;7(6):489-96. doi:10.1002/jhm.1903.
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psnet.ahrq.gov/issue/current-challenges-health-information-technology-related-patient-safety
July 16, 2015 - Commentary
Current challenges in health information technology–related patient safety.
Citation Text:
Sittig DF, Wright A, Coiera E, et al. Current challenges in health information technology–related patient safety. Health Inform J. 2020;26(1):181-189. doi:10.1177/1460458218814893.
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digital.ahrq.gov/ahrq-funded-projects/ai-directed-cds-tool-reduce-iron-deficiency-anemia-pregnancy-randomized
August 01, 2024 - An AI-Directed CDS Tool to Reduce Iron Deficiency Anemia in Pregnancy: A Randomized Controlled Trial (AID-IDA Trial)
Project Description
Integrating a predictive model into the electronic health record (EHR) via a clinical decision support (CDS) tool provides a scalable, resour…
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cds.ahrq.gov/sites/default/files/cds/artifact/106/AMIA_presentation.pptx
January 01, 2012 - Healthy Weight
Stage 1:
Freehand mockup
Stage 2
Wireframe mockup
Stage 3
Interactive module
Stage 4
User testing … Stage 1
Quick, easy, low overhead, adaptable
Stage 2
Layout, spacing, internal workflow (white box testing … Testing before implementation
Everything functions as expected
Patient data is appropriately handled … The CDS does not break the EHR
Testing after implementation
How do different clinical workflows impact … is possible
Even minimally tested CDS can have an immediate impact on patient care, but inadequate testing