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psnet.ahrq.gov/issue/sharing-process-diagnostic-decision-making
January 19, 2022 - Commentary
Sharing the process of diagnostic decision making.
Citation Text:
Brush JE, Brophy JM. Sharing the Process of Diagnostic Decision Making. JAMA Intern Med. 2017;177(9):1245-1246. doi:10.1001/jamainternmed.2017.1929.
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psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis
August 28, 2019 - Commentary
Root cause analysis of cases involving diagnosis.
Citation Text:
Graber ML, Castro GM, Danforth M, et al. Root cause analysis of cases involving diagnosis. Diagnosis (Berl). 2024;11(4):353-368. doi:10.1515/dx-2024-0102.
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psnet.ahrq.gov/issue/organisational-learning-hospitals-concept-analysis
August 21, 2019 - Review
Organisational learning in hospitals: a concept analysis.
Citation Text:
Lyman B, Hammond EL, Cox JR. Organisational learning in hospitals: A concept analysis. J Nurs Manag. 2019;27(3):633-646. doi:10.1111/jonm.12722.
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psnet.ahrq.gov/issue/identifying-safety-hazards-associated-intravenous-vancomycin-through-analysis-patient-safety
January 25, 2023 - Study
Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports.
Citation Text:
Krukas A, Franklin ES, Bonk C, et al. Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety even…
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psnet.ahrq.gov/issue/real-malady-marcel-proust-and-what-it-reveals-about-diagnostic-errors-medicine
September 27, 2022 - Commentary
The real malady of Marcel Proust and what it reveals about diagnostic errors in medicine.
Citation Text:
Douglas Y. The real malady of Marcel Proust and what it reveals about diagnostic errors in medicine. Med Hypotheses. 2016;90:14-8. doi:10.1016/j.mehy.2016.02.024.
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psnet.ahrq.gov/issue/how-communication-failed-or-saved-day-counterfactual-accounts-medical-errors
September 21, 2022 - Study
How communication "failed" or "saved the day": counterfactual accounts of medical errors.
Citation Text:
Street RL, Petrocelli JV, Amroze A, et al. How Communication “Failed” or “Saved the Day”: Counterfactual Accounts of Medical Errors. J Patient Exp. 2020;7(6):1247-1254. doi:10.1…
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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/patient-safety-professionals-third-victims-adverse-events
July 07, 2021 - Commentary
Patient safety professionals as the third victims of adverse events.
Citation Text:
Holden J, Card AJ. Patient safety professionals as the third victims of adverse events. J Patient Saf Risk Manag. 2019;24(4):166-175. doi:10.1177/2516043519850914.
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psnet.ahrq.gov/issue/path-diagnostic-excellence-includes-feedback-calibrate-how-clinicians-think
May 04, 2022 - Commentary
Emerging Classic
The path to diagnostic excellence includes feedback to calibrate how clinicians think.
Citation Text:
Meyer AND, Singh H. The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians Think. JAMA. 2019;321(8):737-738…
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psnet.ahrq.gov/issue/addressing-medicines-bias-against-patients-who-are-overweight
May 15, 2019 - Commentary
Addressing medicine's bias against patients who are overweight.
Citation Text:
Rubin R. Addressing Medicine's Bias Against Patients Who Are Overweight. JAMA. 2019;321(10):925-927. doi:10.1001/jama.2019.0048.
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psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
August 21, 2005 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism.
Citation Text:
Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/code-status-confusion
September 01, 2006 - SPOTLIGHT CASE
Code Status Confusion
Citation Text:
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/issue/better-surgeons-notes-performance
February 06, 2018 - Book/Report
Better: A Surgeon's Notes on Performance.
Citation Text:
Better: A Surgeon's Notes on Performance. Gawande A. New York, NY: Metropolitan; 2007.
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psnet.ahrq.gov/issue/role-chief-executive-officer-maximizing-patient-safety
January 03, 2017 - Newspaper/Magazine Article
The role of the chief executive officer in maximizing patient safety.
Citation Text:
Shorr AS. The role of the chief executive officer in maximizing patient safety. Healthcare executive. 2007;22(2):20-2, 24, 26.
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psnet.ahrq.gov/issue/systematic-review-evidence-publishing-patient-care-performance-data-improves-quality-care
September 06, 2017 - Review
Systematic review: the evidence that publishing patient care performance data improves quality of care.
Citation Text:
Fung CH, Lim Y-W, Mattke S, et al. Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med. 2008;…
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psnet.ahrq.gov/issue/preventing-medication-errors-21-billion-opportunity
December 03, 2008 - Fact Sheet/FAQs
Preventing Medication Errors: A $21 Billion Opportunity.
Citation Text:
Preventing Medication Errors: A $21 Billion Opportunity. Washington, DC: National Priorities Partnership and National Quality Forum; December 2010.
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psnet.ahrq.gov/issue/hard-look-hard-stops-and-workarounds-acute-care-setting
June 26, 2013 - Newspaper/Magazine Article
A hard look at hard stops and workarounds in the acute care setting.
Citation Text:
A hard look at hard stops and workarounds in the acute care setting. ISMP Medication Safety Alert! Acute care edition. June 29, 2023;28(13);1-4.
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psnet.ahrq.gov/issue/national-and-state-healthcare-associated-infections-progress-report
June 11, 2014 - Book/Report
National and State Healthcare-Associated Infections Progress Report.
Citation Text:
National and State Healthcare-Associated Infections Progress Report. Atlanta, GA: Centers for Disease Control and Prevention; November 2023.
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psnet.ahrq.gov/issue/managing-risks-organizational-accidents
May 13, 2011 - Book/Report
Classic
Managing the Risks of Organizational Accidents.
Citation Text:
Managing the Risks of Organizational Accidents. Reason JT. Aldershot, Hants, England: Ashgate: 1997. ISBN: 9781840141047
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psnet.ahrq.gov/issue/input-teamstepps-curriculum-updates
December 24, 2008 - Press Release/Announcement
Input for the TeamSTEPPS Curriculum Updates.
Citation Text:
Input for the TeamSTEPPS Curriculum Updates. Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021.
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