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psnet.ahrq.gov/issue/implementing-hospital-based-communication-and-resolution-programs-lessons-learned-new-york
September 01, 2018 - Study
Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.
Citation Text:
Mello MM, Senecal SK, Kuznetsov Y, et al. Implementing hospital-based communication-and-resolution programs: lessons learned in New York City. Health Aff (Millwood).…
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psnet.ahrq.gov/issue/state-science-human-factors-and-ergonomics-healthcare
April 01, 2015 - Commentary
State of science: human factors and ergonomics in healthcare.
Citation Text:
Hignett S, Carayon P, Buckle P, et al. State of science: human factors and ergonomics in healthcare. Ergonomics. 2013;56(10):1491-503. doi:10.1080/00140139.2013.822932.
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psnet.ahrq.gov/issue/ambiguity-and-workarounds-contributors-medical-error
December 23, 2008 - Commentary
Ambiguity and workarounds as contributors to medical error.
Citation Text:
Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med. 2005;142(8):627-630.
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psnet.ahrq.gov/issue/case-study-identifying-potential-problems-humantechnical-interface-complex-clinical-systems
July 22, 2009 - Commentary
Case study: identifying potential problems at the human/technical interface in complex clinical systems.
Citation Text:
Caudill-Slosberg M, Weeks WB. Case study: identifying potential problems at the human/technical interface in complex clinical systems. Am J Med Qual. 2005;…
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psnet.ahrq.gov/issue/identification-and-prioritization-health-it-patient-safety-measures
September 29, 2017 - Book/Report
Classic
Identification and Prioritization of Health IT Patient Safety Measures.
Citation Text:
Identification and Prioritization of Health IT Patient Safety Measures. Washington, DC: National Quality Forum; February 2016.
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psnet.ahrq.gov/issue/complexity-bias-prevention-iatrogenic-injury-why-specific-harms-may-inhibit-performance
September 23, 2020 - Commentary
Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance.
Citation Text:
Padula WV, Armstrong DG, Goldman DP. Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. Mayo Clin Proc. 2022;97(2…
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psnet.ahrq.gov/issue/nursing-strategies-increase-medication-safety-inpatient-settings
September 21, 2016 - Study
Nursing strategies to increase medication safety in inpatient settings.
Citation Text:
Bravo K, Cochran GL, Barrett R. Nursing Strategies to Increase Medication Safety in Inpatient Settings. J Nurs Care Qual. 2016;31(4):335-41. doi:10.1097/NCQ.0000000000000181.
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psnet.ahrq.gov/issue/nursing-2006-patient-safety-survey-report
March 01, 2023 - Study
Nursing 2006 Patient-safety survey report.
Citation Text:
Manno M, Hogan P, Heberlein V, et al. Nursing 2006. Patient-safety survey report. Nursing (Brux). 2006;36(5):54-64.
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psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa
November 18, 2015 - Book/Report
Classic
The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA.
Citation Text:
The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Vaughan D. Chicago, IL: University of Chicago Press; 1996. ISBN…
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psnet.ahrq.gov/issue/medical-problem-solving-analysis-clinical-reasoning
July 18, 2018 - Book/Report
Classic
Medical Problem Solving: An Analysis of Clinical Reasoning.
Citation Text:
Medical Problem Solving: An Analysis of Clinical Reasoning. Elstein AS, ed. Cambridge, MA: Harvard University Press; 1978. ISBN: 9780674561250.
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psnet.ahrq.gov/issue/ensuring-medication-safety-consumers-ethnic-minority-backgrounds-need-address-unconscious
July 29, 2020 - Commentary
Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscious bias within health systems.
Citation Text:
Chauhan A, Walpola RL. Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscio…
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psnet.ahrq.gov/issue/debrief-imperative-building-teaming-competencies-and-team-effectiveness
December 16, 2020 - Commentary
The debrief imperative: building teaming competencies and team effectiveness.
Citation Text:
Tannenbaum SI, Greilich PE. The debrief imperative: building teaming competencies and team effectiveness. BMJ Qual Saf. 2023;32(3):125-128. doi:10.1136/bmjqs-2022-015259.
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psnet.ahrq.gov/issue/critical-conversations-call-nonprocedural-time-out
February 18, 2011 - Commentary
Critical conversations: a call for a nonprocedural "time out."
Citation Text:
Sehgal NL, Fox M, Sharpe B, et al. Critical conversations: a call for a nonprocedural "time out". J Hosp Med. 2011;6(4):225-30. doi:10.1002/jhm.853.
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psnet.ahrq.gov/issue/health-it-and-patient-safety-building-safer-systems-better-care
June 16, 2011 - Book/Report
Classic
Health IT and Patient Safety: Building Safer Systems for Better Care.
Citation Text:
Health IT and Patient Safety: Building Safer Systems for Better Care. Committee on Patient Safety and Health Information Technology, Board on Health Care Ser…
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psnet.ahrq.gov/issue/pediatric-chest-radiographs-common-and-less-common-errors
September 02, 2020 - Commentary
Pediatric chest radiographs: common and less common errors.
Citation Text:
Menashe SJ, Iyer RS, Parisi MT, et al. Pediatric Chest Radiographs: Common and Less Common Errors. AJR Am J Roentgenol. 2016;207(4):903-911. doi:10.2214/AJR.16.16449.
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psnet.ahrq.gov/issue/what-preventable-harm-healthcare-systematic-review-definitions
September 23, 2020 - Review
What is preventable harm in healthcare? A systematic review of definitions.
Citation Text:
Nabhan M, Elraiyah T, Brown DR, et al. What is preventable harm in healthcare? A systematic review of definitions. BMC Health Serv Res. 2012;12:128. doi:10.1186/1472-6963-12-128.
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psnet.ahrq.gov/issue/procuring-interoperability-achieving-high-quality-connected-and-person-centered-care
September 19, 2018 - Book/Report
Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care.
Citation Text:
Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of M…
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psnet.ahrq.gov/issue/girl-who-died-twice-every-patients-nightmare-libby-zion-case-and-hidden-hazards-hospitals
May 09, 2018 - Book/Report
Classic
The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals.
Citation Text:
The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals. Robins NS…
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psnet.ahrq.gov/issue/organisational-failure-rethinking-whistleblowing-tomorrows-doctors
May 18, 2022 - Commentary
Organisational failure: rethinking whistleblowing for tomorrow's doctors.
Citation Text:
Taylor DJ, Goodwin D. Organisational failure: rethinking whistleblowing for tomorrow’s doctors. J Med Ethics. 2022;48(10):672-677. doi:10.1136/jme-2022-108328.
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psnet.ahrq.gov/issue/safety-performance-and-satisfaction-outcomes-operating-room-literature-review
April 03, 2019 - Review
Emerging Classic
Safety, performance, and satisfaction outcomes in the operating room: a literature review.
Citation Text:
Joseph A, Bayramzadeh S, Zamani Z, et al. Safety, Performance, and Satisfaction Outcomes in the Operating Room: A Literature Review.…