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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - Medication Administration Errors
Citation Text:
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - Wrong Catheter in the Right Patient
Citation Text:
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - SPOTLIGHT CASE
When the Indications for Drug Administration Blur
Citation Text:
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - SPOTLIGHT CASE
The Other Side
Citation Text:
Vincent CA. The Other Side. 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/node/49705/psn-pdf
January 01, 2020 - A "Reflexive" Diagnosis in Primary Care
April 1, 2014
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
Case Objectives
Appreciate that primary care doctors may be caring for an increasing number of patients wi…
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psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - The "Customer" Is Always Right
February 1, 2007
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/customer-always-right
Case Objectives
Understand the importance of identifying a patient's agenda.
Appreciate the factors that contribute to unmet patient expectations.
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psnet.ahrq.gov/issue/hidden-dangers-outsourcing-radiology
December 19, 2007 - Newspaper/Magazine Article
The hidden dangers of outsourcing radiology.
Citation Text:
The hidden dangers of outsourcing radiology. Eban K.
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psnet.ahrq.gov/node/39714/psn-pdf
April 14, 2011 - US public opinion regarding proposed limits on resident
physician work hours.
April 14, 2011
Blum AB, Raiszadeh F, Shea S, et al. US public opinion regarding proposed limits on resident physician
work hours. BMC Med. 2010;8:33. doi:10.1186/1741-7015-8-33.
https://psnet.ahrq.gov/issue/us-public-opinion-regarding-pr…
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psnet.ahrq.gov/issue/ihinpsf-lucian-leape-institute
July 12, 2017 - Multi-use Website
IHI Lucian Leape Institute.
Citation Text:
IHI Lucian Leape Institute. Institute for Healthcare Improvement.
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psnet.ahrq.gov/issue/talkingquality
December 24, 2008 - Multi-use Website
TalkingQuality.
Citation Text:
TalkingQuality. Agency for Healthcare Research and Quality.
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psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system-failures
July 31, 2023 - Sentinel Event Alerts
Preventing adverse events caused by emergency electrical power system failures.
Citation Text:
Preventing adverse events caused by emergency electrical power system failures. Sentinel Event Alert. 2006;37(37):1-3.
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psnet.ahrq.gov/node/40392/psn-pdf
February 10, 2015 - 'Global Trigger Tool' shows that adverse events in
hospitals may be ten times greater than previously
measured.
February 10, 2015
Classen D, Resar RK, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten
times greater than previously measured. Health Aff (Millwood). 2011;30(4):…
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psnet.ahrq.gov/issue/patient-safety-0
February 28, 2015 - Government Resource
Patient Safety.
Citation Text:
Patient Safety. Minnesota Department of Health
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November …
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psnet.ahrq.gov/node/837194/psn-pdf
January 01, 2023 - National improvements in resident physician-reported
patient safety after limiting first-year resident physicians'
extended duration work shifts: a pooled analysis of
prospective cohort studies.
May 25, 2022
Weaver MD, Landrigan CP, Sullivan JP, et al. National improvements in resident physician-reported patient
…
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psnet.ahrq.gov/node/40578/psn-pdf
July 06, 2011 - Implementing the 2009 Institute of Medicine
recommendations on resident physician work hours,
supervision, and safety.
July 6, 2011
Blum AB, Shea AS, Czeisler CA, et al. Implementing the 2009 Institute of Medicine recommendations on
resident physician work hours, supervision, and safety. Nat Sci Sleep. 2011;3:47-8…
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psnet.ahrq.gov/issue/safemedicationuseca
October 10, 2012 - Multi-use Website
SafeMedicationUse.ca.
Citation Text:
SafeMedicationUse.ca. Institute for Safe Medication Practices Canada; ISMP Canada.
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psnet.ahrq.gov/node/44434/psn-pdf
June 21, 2016 - Hospital board and management practices are strongly
related to hospital performance on clinical quality
metrics.
June 21, 2016
Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to
hospital performance on clinical quality metrics. Health Aff (Millwood). 2015;34(8):130…
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psnet.ahrq.gov/node/39617/psn-pdf
February 18, 2011 - Potential unintended consequences due to Medicare's
"No Pay for Errors Rule"? A randomized controlled trial of
an educational intervention with internal medicine
residents.
February 18, 2011
Mookherjee S, Vidyarthi AR, Ranji SR, et al. Potential Unintended Consequences Due to Medicare’s “No
Pay for Errors Rule”? …