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psnet.ahrq.gov/issue/medication-order-errors-hospital-admission-among-children-medical-complexity
July 20, 2022 - Study
Medication order errors at hospital admission among children with medical complexity
Citation Text:
Blaine K, Wright J, Pinkham A, et al. Medication Order Errors at Hospital Admission Among Children With Medical Complexity. J Patient Saf. 2022;18(1):e156-e162. doi:10.1097/pts.00000…
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psnet.ahrq.gov/issue/improving-safety-during-transitions-care-through-use-electronic-referral-loops-receive-and
October 19, 2022 - Study
Improving safety during transitions of care through the use of electronic referral loops to receive and reconcile health information.
Citation Text:
Allen G, Setzer J, Jones R, et al. Improving safety during transitions of care through the use of electronic referral loops to receiv…
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psnet.ahrq.gov/issue/patient-participation-surgical-site-marking-can-be-additional-tool-help-avoid-wrong-site
March 14, 2022 - Study
Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surgery?
Citation Text:
Bergal LM, Schwarzkopf R, Walsh M, et al. Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surger…
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psnet.ahrq.gov/issue/incidence-adverse-events-among-home-care-patients
December 04, 2015 - Study
The incidence of adverse events among home care patients.
Citation Text:
Sears NA, Baker R, Barnsley J, et al. The incidence of adverse events among home care patients. Int J Qual Health Care. 2013;25(1):16-28. doi:10.1093/intqhc/mzs075.
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psnet.ahrq.gov/issue/clinicians-perspectives-proactive-patient-safety-behaviors-perioperative-environment
May 24, 2023 - Study
Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment.
Citation Text:
Duffy C, Menon N, Horak D, et al. Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment. JAMA Netw Open. 2023;6(4):e237621. doi:…
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psnet.ahrq.gov/issue/double-checking-second-look
August 28, 2017 - Study
Double checking: a second look.
Citation Text:
Hewitt T, Chreim S, Forster AJ. Double checking: a second look. J Eval Clin Pract. 2016;22(2):267-74. doi:10.1111/jep.12468.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
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psnet.ahrq.gov/issue/what-scale-prescribing-errors-committed-junior-doctors-systematic-review
January 30, 2013 - Review
What is the scale of prescribing errors committed by junior doctors? A systematic review.
Citation Text:
Ross S, Bond C, Rothnie H, et al. What is the scale of prescribing errors committed by junior doctors? A systematic review. Br J Clin Pharmacol. 2009;67(6):629-40. doi:10.111…
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psnet.ahrq.gov/issue/patient-safety-incidents-endoscopy-human-factors-analysis-non-procedural-significant-harm
January 29, 2020 - Study
Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents from the National Reporting and Learning System (NRLS).
Citation Text:
Ravindran S, Matharoo M, Rutter MD, et al. Patient safety incidents in endoscopy: a human factors anal…
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psnet.ahrq.gov/issue/levels-agreement-grading-analysis-and-reporting-significant-events-general-practitioners
April 06, 2011 - Study
Levels of agreement on the grading, analysis and reporting of significant events by general practitioners: a cross-sectional study.
Citation Text:
McKay J, Bowie P, Murray L, et al. Levels of agreement on the grading, analysis and reporting of significant events by general practit…
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psnet.ahrq.gov/issue/opioids-prescribed-after-low-risk-surgical-procedures-united-states-2004-2012
May 29, 2024 - Study
Opioids prescribed after low-risk surgical procedures in the United States, 2004–2012.
Citation Text:
Wunsch H, Wijeysundera DN, Passarella MA, et al. Opioids Prescribed After Low-Risk Surgical Procedures in the United States, 2004-2012. JAMA. 2016;315(15):1654-7. doi:10.1001/jama.…
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psnet.ahrq.gov/issue/closing-loop-ambulatory-staff-safety-reports
April 22, 2016 - Study
Closing the loop with ambulatory staff on safety reports.
Citation Text:
Williams S, Fiumara K, Kachalia A, et al. Closing the Loop with Ambulatory Staff on Safety Reports. Jt Comm J Qual Saf. 2020;46(1):44-50. doi:10.1016/j.jcjq.2019.09.009.
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psnet.ahrq.gov/issue/differential-perceptions-what-constitutes-medical-error-associated-electronic-medical-records
August 09, 2023 - Commentary
Differential perceptions of what constitutes a medical error associated with electronic medical records.
Citation Text:
Koppel R, Kuziemsky C, Elkin PL, et al. Differential perceptions of what constitutes a medical error associated with electronic medical records. Stud Health …
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psnet.ahrq.gov/issue/patient-safety-related-hospital-deaths-england-thematic-analysis-incidents-reported-national
October 31, 2014 - Study
Patient-safety–related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012.
Citation Text:
Donaldson LJ, Panesar S, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national da…
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psnet.ahrq.gov/issue/implementing-delivery-room-checklists-and-communication-standards-multi-neonatal-icu-quality
November 20, 2019 - Study
Implementing delivery room checklists and communication standards in a multi-neonatal ICU quality improvement collaborative.
Citation Text:
Bennett SC, Finer N, Halamek LP, et al. Implementing Delivery Room Checklists and Communication Standards in a Multi-Neonatal ICU Quality Impr…
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psnet.ahrq.gov/issue/contributing-factors-identified-hospital-incident-report-narratives
January 02, 2017 - Study
Contributing factors identified by hospital incident report narratives.
Citation Text:
Nuckols TK, Bell DS, Paddock SM, et al. Contributing factors identified by hospital incident report narratives. Qual Saf Health Care. 2008;17(5):368-72. doi:10.1136/qshc.2007.023721.
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psnet.ahrq.gov/issue/pathologists-perspectives-disclosing-harmful-pathology-error
January 22, 2020 - Study
Pathologists' perspectives on disclosing harmful pathology error.
Citation Text:
Dintzis SM, Clennon EK, Prouty CD, et al. Pathologists' Perspectives on Disclosing Harmful Pathology Error. Arch Pathol Lab Med. 2017;141(6):841-845. doi:10.5858/arpa.2016-0136-OA.
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psnet.ahrq.gov/node/49403/psn-pdf
June 01, 2003 - Missed Appendicitis
June 1, 2003
Adams JG. Missed Appendicitis. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missed-appendicitis
Case Objectives
Appreciate the variable presentations of appendicitis
List complications of missed appendicitis
Understand the advantages and disadvantages of CT in diagnosing…
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psnet.ahrq.gov/node/49833/psn-pdf
June 01, 2018 - Perils in Diagnosing a Stroke
June 1, 2018
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
The Case
A 75-year-old man with a history of hypertension, diabetes, chronic back pain, and opioid use disorder was
brought to the emergency depart…
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psnet.ahrq.gov/node/49809/psn-pdf
October 01, 2017 - Hyperbilirubinemia Refractory to Phototherapy
October 1, 2017
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
The Case
A 1-day-old full-term infant was noted to have elevated total serum bilirubin (…
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - July Syndrome
June 1, 2016
Young JQ. July Syndrome. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/july-syndrome
The Case
A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower
lobe lung cancer. The attending surgeon saw the patient along with his fellow,…