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psnet.ahrq.gov/issue/plague-year-mistakes-and-struggles-behind-americas-covid-19-tragedy
September 04, 2013 - Newspaper/Magazine Article
The plague year. The mistakes and the struggles behind America’s coronavirus tragedy.
Citation Text:
The plague year. The mistakes and the struggles behind America’s coronavirus tragedy. Wright L. New Yorker. January 4, 2021;96(463):20-59.
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psnet.ahrq.gov/issue/commentary-sentinel-serious-events-reported-district-health-boards-200607
March 05, 2008 - Book/Report
Commentary on Sentinel & Serious Events Reported by District Health Boards - 2006/07.
Citation Text:
Commentary on Sentinel & Serious Events Reported by District Health Boards - 2006/07. National Health Epidemiology and Quality Assurance Advisory Committee. Wellington, Ne…
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psnet.ahrq.gov/issue/serious-reportable-events
March 21, 2018 - Government Resource
Serious Reportable Events.
Citation Text:
Serious Reportable Events. Nova Scotia Department of Health and Wellness.
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psnet.ahrq.gov/issue/safety-maternity-services-england
February 04, 2015 - Book/Report
The Safety of Maternity Services in England.
Citation Text:
The Safety of Maternity Services in England. Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19.
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psnet.ahrq.gov/issue/perruche-case-and-issue-compensation-consequences-medical-error
July 31, 2024 - Commentary
The Perruche case and the issue of compensation for the consequences of medical error.
Citation Text:
Costich JF. The Perruche case and the issue of compensation for the consequences of medical error. Health Policy (New York). 2006;78(1):8-16.
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - For example, we used baby monitors in some patients’ rooms so nursing
could be responsive and monitor … Our medication safety team had to
use barcode scanning outside of the patient room and then use baby
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - As the obstetric team was in a hurry to deliver the baby, the team huddle
was rushed. … • A live baby girl was born with an Apgar score of 10 at 5 minutes.
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psnet.ahrq.gov/issue/second-victim-review
June 26, 2019 - Review
The second victim: a review.
Citation Text:
Coughlan B, Powell D, Higgins MF. The Second Victim: a Review. Eur J Obstet Gynecol Reprod Biol. 2017;213:11-16. doi:10.1016/j.ejogrb.2017.04.002.
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psnet.ahrq.gov/issue/she-hoped-shine-light-maternal-mortality-among-native-americans-instead-she-became-statistic
July 22, 2020 - Newspaper/Magazine Article
She hoped to shine a light on maternal mortality among Native Americans. Instead, she became a statistic of it.
Citation Text:
She hoped to shine a light on maternal mortality among Native Americans. Instead, she became a statistic of it. Chuck E, Assefa H. N…
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psnet.ahrq.gov/issue/mid-staffs-scandal-10-years-inquiry-chair-worries-nhs-staff-too-scared-speak
December 18, 2019 - Newspaper/Magazine Article
Mid Staffs scandal: 10 years on, inquiry chair worries NHS staff too scared to speak up.
Citation Text:
Mid Staffs scandal: 10 years on, inquiry chair worries NHS staff too scared to speak up. Lintern S. The Independent. January 15, 2020.
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - As the obstetric team was in a hurry to deliver the baby, the team huddle was rushed. … A live baby girl was born with an Apgar score of 10 at 5 minutes.
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psnet.ahrq.gov/issue/changing-practice-improve-patient-safety-and-quality-care-perinatal-medicine
November 18, 2016 - Review
Changing practice to improve patient safety and quality of care in perinatal medicine.
Citation Text:
Kaplan HC, Ballard J. Changing Practice to Improve Patient Safety and Quality of Care in Perinatal Medicine. Am J Perinatol. 2011;29(01). doi:10.1055/s-0031-1285826.
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psnet.ahrq.gov/node/33875/psn-pdf
March 01, 2019 - In Conversation With… Susan Haas, MD, MSc
March 1, 2019
In Conversation With… Susan Haas, MD, MSc. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
Editor's note: Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs'
work focused on health…
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psnet.ahrq.gov/issue/mistaken-identity-skin-cleansing-solution-leading-extensive-chemical-burns-extremely-preterm
October 19, 2022 - Commentary
Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant.
Citation Text:
Mannan K, Chow P, Lissauer T, et al. Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infan…
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psnet.ahrq.gov/issue/understanding-factors-impact-health-care-professionals-risk-perceptions-and-responses-toward
June 22, 2022 - Review
Understanding factors that impact on health care professionals' risk perceptions and responses toward Clostridium difficile and methicillin-resistant Staphylococcus aureus: a structured literature review.
Citation Text:
Burnett E, Kearney N, Johnston B, et al. Understanding fact…
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psnet.ahrq.gov/issue/measures-patient-safety-developing-and-emerging-countries-review-literature
April 05, 2017 - Review
Measures of patient safety in developing and emerging countries: a review of the literature.
Citation Text:
Carpenter KB, Duevel MA, Lee PW, et al. Measures of patient safety in developing and emerging countries: a review of the literature. Qual Saf Health Care. 2010;19(1):48-54…
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psnet.ahrq.gov/issue/more-teamwork-knowledge-skill-and-attitude
July 13, 2009 - Study
More to teamwork than knowledge, skill and attitude.
Citation Text:
Siassakos D, Draycott TJ, Crofts JF, et al. More to teamwork than knowledge, skill and attitude. BJOG. 2010;117(10):1262-9. doi:10.1111/j.1471-0528.2010.02654.x.
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psnet.ahrq.gov/issue/reversing-rise-maternal-mortality
January 18, 2017 - Commentary
Reversing the rise in maternal mortality.
Citation Text:
Kozhimannil KB. Reversing The Rise In Maternal Mortality. Health Aff (Millwood). 2018;37(11):1901-1904. doi:10.1377/hlthaff.2018.1013.
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psnet.ahrq.gov/issue/liability-reform-should-make-patients-safer-avoidable-classes-events-are-key-improvement
July 26, 2023 - Commentary
Liability reform should make patients safer: "Avoidable classes of events" are a key improvement.
Citation Text:
Bovbjerg RR, Tancredi LR. Liability reform should make patients safer: "avoidable classes of events" are a key improvement. J Law Med Ethics. 2005;33(3):478-500. …
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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - For example, we used baby monitors in some patients’ rooms so nursing could be responsive and monitor … Our medication safety team had to use barcode scanning outside of the patient room and then use baby … For example, the use of baby monitors (which include cameras) with patients in isolation can allow for