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psnet.ahrq.gov/node/33664/psn-pdf
March 01, 2008 - In Conversation with...Bradley T. Rosen, MD, MBA
March 1, 2008
In Conversation with..Bradley T. Rosen, MD, MBA. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
Editor's note: Dr. Rosen is Medical Director of the Inpatient Specialty Program (ISP) Hospitalist service…
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psnet.ahrq.gov/node/33807/psn-pdf
May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD
May 1, 2016
In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
Editor's note: Dr. Drew, a nurse researcher, is the David Mortara Distinguished Professor of Physiological
Nursing and…
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - Tough Call: Addressing Errors From Previous Providers
March 1, 2014
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
Case Objectives
Define what it means to be a professional.
Identi…
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Getting the Diagnosis Both Right and Wrong
Citation Text:
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - Failure to Report
March 1, 2007
Spath P. Failure to Report. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/failure-report
Case Objectives
List common causes of medical errors.
Appreciate the magnitude of underreporting of adverse events.
List the common barriers to reporting adverse events and near misses…
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psnet.ahrq.gov/node/40725/psn-pdf
October 16, 2012 - Association of ICU or hospital admission with
unintentional discontinuation of medications for chronic
diseases.
October 16, 2012
Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional
discontinuation of medications for chronic diseases. JAMA. 2011;306(8):840-7.
doi:10.10…
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psnet.ahrq.gov/issue/discontinuity-and-disaster-gaps-and-negotiation-culpability-medication-delivery
June 24, 2020 - Commentary
Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery.
Citation Text:
Dekker SWA. Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. J Law Med Ethics. 2007;35(3):463-70.
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psnet.ahrq.gov/issue/strategies-learning-failure
September 25, 2024 - Commentary
Classic
Strategies for learning from failure.
Citation Text:
Edmondson A. Strategies of learning from failure. Harv Bus Rev. 2011;89(4):48-55, 137.
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psnet.ahrq.gov/issue/patient-safety-7
November 16, 2015 - Book/Report
Patient Safety.
Citation Text:
Patient Safety. Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
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Save to your library
Print
…
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psnet.ahrq.gov/issue/nurses-role-patient-safety
June 09, 2011 - Commentary
Nurses' role in patient safety.
Citation Text:
Hughes RG, Clancy CM. Nurses' role in patient safety. J Nurs Care Qual. 2009;24(1):1-4. doi:10.1097/NCQ.0b013e31818f55c7.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/issue/systematic-review-incidence-and-characteristics-preventable-adverse-drug-events-ambulatory
July 15, 2010 - Review
Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care.
Citation Text:
Thomsen LA, Winterstein AG, S⊘ndergaard B, et al. Systematic Review of the Incidence and Characteristics of Preventable Adverse Drug Events in Ambulatory …
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psnet.ahrq.gov/issue/nursing-student-errors-and-near-misses-three-years-data
October 20, 2021 - Study
Nursing student errors and near misses: three years of data.
Citation Text:
Silvestre JH, Spector ND. Nursing student errors and near misses: three years of data. J Nurs Educ. 2023;62(1):12-19. doi:10.3928/01484834-20221109-05.
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DOI Google Scholar…
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psnet.ahrq.gov/issue/ambulance-stretcher-adverse-events
March 23, 2011 - Study
Ambulance stretcher adverse events.
Citation Text:
Wang HE, Weaver MD, Abo BN, et al. Ambulance stretcher adverse events. Qual Saf Health Care. 2009;18(3):213-216. doi:10.1136/qshc.2007.024562.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/node/38956/psn-pdf
March 18, 2015 - Safety in Doses.
March 18, 2015
London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088.
https://psnet.ahrq.gov/issue/safety-doses
This publication analyzes 72,482 medication incidents reported to the National Health Service and
highlights areas for improvement and prevention.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/41998/psn-pdf
January 30, 2013 - Involving Patients in Improving Safety.
January 30, 2013
London, UK: The Health Foundation; January 2013.
https://psnet.ahrq.gov/issue/involving-patients-improving-safety
This review analyzes research on engaging patients in safety improvement and details which strategies are
most effective.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/39591/psn-pdf
March 21, 2016 - Annual Benchmarking Report: Malpractice Risks in
Surgery.
March 21, 2016
Cambridge, MA: CRICO/RMF Strategies; 2010.
https://psnet.ahrq.gov/issue/annual-benchmarking-report-malpractice-risks-surgery
Analyzing data from 3300 surgical malpractice cases, this report describes errors across the continuum of
surgical c…
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psnet.ahrq.gov/node/37765/psn-pdf
May 24, 2015 - The Rebecca O'Malley Report.
May 24, 2015
Cork, Ireland: Health Information and Quality Authority; March 21, 2008.
https://psnet.ahrq.gov/issue/rebecca-omalley-report
This report analyzes the findings of a diagnostic error investigation and provides numerous
recommendations to improve standards for treating sympto…
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psnet.ahrq.gov/node/37560/psn-pdf
March 28, 2018 - Learning from Investigations.
March 28, 2018
Commission for Healthcare Audit and Inspection. London, England; Healthcare Commission: 2008. ISBN
9781845621636.
https://psnet.ahrq.gov/issue/learning-investigations
Analyzing health care failures from 2004-2007 in the United Kingdom, this report identifies common them…
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psnet.ahrq.gov/issue/using-six-sigma-reduce-medication-errors-home-delivery-pharmacy-service
November 18, 2015 - Study
Using Six Sigma to reduce medication errors in a home-delivery pharmacy service.
Citation Text:
Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24.
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…
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psnet.ahrq.gov/issue/complication-rates-weekends-and-weekdays-us-hospitals
August 31, 2011 - Study
Complication rates on weekends and weekdays in US hospitals.
Citation Text:
Bendavid E, Kaganova Y, Needleman J, et al. Complication rates on weekends and weekdays in US hospitals. Am J Med. 2007;120(5):422-8.
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