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psnet.ahrq.gov/node/33861/psn-pdf
July 01, 2018 - In Conversation With… Gordon Schiff, MD
July 1, 2018
In Conversation With… Gordon Schiff, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
Editor's note: Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research
and Practice, Associate Pr…
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psnet.ahrq.gov/node/49818/psn-pdf
January 01, 2018 - A Costly Colonoscopy Leads to a Delay in Diagnosis
January 1, 2018
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
The Case
A 50-year-old man presented to a primary care clinic to establish care, as he ha…
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Browse Author Resources
Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - Care Transitions
Sunil Kripalani, MD, MSc | December 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Kripalani S. Care Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depart…
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psnet.ahrq.gov/sites/default/files/2020-04/final_april-spotlight-implicit_biases_04.02.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Implicit Biases, Interprofessional
Communication, and Power
Dynamics
Source and Credits
• This presentation is based on the April 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Erin Stephany Sanchez, MD, Melody Tran-
Reina, MD, Kupi…
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psnet.ahrq.gov/periodic-issue/periodic-issue-460
October 30, 2024 - October 9, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports…
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding
September 1, 2017
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
Case Objectives
Describe risk factors for poor outcome in patients w…
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
May 01, 2009 - Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556-1564. [go to PubMed]
2.
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psnet.ahrq.gov/periodic-issue/periodic-issue-430
March 27, 2024 - This qualitative study explored how sociotechnical systems contribute to adverse drug events (ADEs) in
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - SPOTLIGHT CASE
The Case of Mistaken Intubation
Citation Text:
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX End…
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psnet.ahrq.gov/web-mm/air-side-caution
April 21, 2015 - Air on the Side of Caution
Citation Text:
Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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psnet.ahrq.gov/node/49536/psn-pdf
May 01, 2007 - On the Other Hand
May 1, 2007
Henneman EA. On the Other Hand. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/other-hand
The Case
A young woman with Takayasu's arteritis presented to the hospital with severe abdominal pain. The patient
had been diagnosed with Takayasu's a decade earlier. The disease results…
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - SPOTLIGHT CASE
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.
Citation Text:
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
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psnet.ahrq.gov/node/837959/psn-pdf
August 31, 2022 - Perioperative Anaphylaxis After Insertion of a Latex Drain
in a Patient with Known Latex Allergy
August 31, 2022
Kelly KJ. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertio…
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psnet.ahrq.gov/node/49783/psn-pdf
February 01, 2017 - The Hazards of Distraction: Ticking All the EHR Boxes
February 1, 2017
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
Case Objectives
List the goals of having order sets in the electronic health record…
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psnet.ahrq.gov/perspective/safety-radiology
October 01, 2013 - February 14, 2024
Evaluation of accuracy of IHI Trigger Tool in identifying adverse drug … events: a prospective observational study.
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - Systems analysis of adverse drug events. J Am Med Assoc . 1995;274(1):35-43.
Farrell G.
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psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
March 04, 2020 - The Hidden Harms of Hand Sanitizer
Citation Text:
Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/node/33659/psn-pdf
October 01, 2007 - Making Just Culture a Reality: One Organization's
Approach
October 1, 2007
Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
Perspective
We've all been there...something goes wrong,…
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psnet.ahrq.gov/node/33689/psn-pdf
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary,
Promoter of Patient Safety
October 1, 2009
Wachter R. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety. PSNet [internet].
2009.
https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
Perspective
…