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psnet.ahrq.gov/node/42133/psn-pdf
March 27, 2013 - Acceptance of recommendations by inpatient pharmacy
case managers: unintended consequences of hospitalist … Acceptance of recommendations by inpatient pharmacy case
managers: unintended consequences of hospitalist … https://psnet.ahrq.gov/issue/acceptance-recommendations-inpatient-pharmacy-case-managers-
unintended-consequences … https://psnet.ahrq.gov/issue/acceptance-recommendations-inpatient-pharmacy-case-managers-unintended-consequences … https://psnet.ahrq.gov/issue/acceptance-recommendations-inpatient-pharmacy-case-managers-unintended-consequences
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psnet.ahrq.gov/node/35244/psn-pdf
December 17, 2008 - Representative case series from public hospital
admissions 1998 II: surgical adverse events. … Representative case series from public hospital admissions 1998 II:
surgical adverse events. … https://psnet.ahrq.gov/issue/representative-case-series-public-hospital-admissions-1998-ii-surgical- … https://psnet.ahrq.gov/issue/representative-case-series-public-hospital-admissions-1998-ii-surgical-adverse-events … https://psnet.ahrq.gov/issue/representative-case-series-public-hospital-admissions-1998-ii-surgical-adverse-events
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psnet.ahrq.gov/node/39559/psn-pdf
December 17, 2010 - Understanding vs. competency: the case of accuracy
checking dispensed medicines in pharmacy. … Understanding vs. competency: the case of accuracy checking
dispensed medicines in pharmacy. … https://psnet.ahrq.gov/issue/understanding-vs-competency-case-accuracy-checking-dispensed-medicines- … https://psnet.ahrq.gov/issue/understanding-vs-competency-case-accuracy-checking-dispensed-medicines-pharmacy … https://psnet.ahrq.gov/issue/understanding-vs-competency-case-accuracy-checking-dispensed-medicines-pharmacy
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psnet.ahrq.gov/node/47730/psn-pdf
January 23, 2019 - Assessment of a simulated case-based measurement of
physician diagnostic performance. … Assessment of a Simulated Case-Based Measurement of
Physician Diagnostic Performance. … https://psnet.ahrq.gov/issue/assessment-simulated-case-based-measurement-physician-diagnostic-
performance … https://psnet.ahrq.gov/issue/assessment-simulated-case-based-measurement-physician-diagnostic-performance … https://psnet.ahrq.gov/issue/assessment-simulated-case-based-measurement-physician-diagnostic-performance
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psnet.ahrq.gov/node/42359/psn-pdf
September 01, 2016 - A clinical case of electronic health record drug alert
fatigue: consequences for patient outcome. … A clinical case of electronic health record drug alert
fatigue: consequences for patient outcome. … https://psnet.ahrq.gov/issue/clinical-case-electronic-health-record-drug-alert-fatigue-consequences-patient … https://psnet.ahrq.gov/issue/clinical-case-electronic-health-record-drug-alert-fatigue-consequences-patient-outcome … https://psnet.ahrq.gov/issue/clinical-case-electronic-health-record-drug-alert-fatigue-consequences-patient-outcome
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psnet.ahrq.gov/node/40530/psn-pdf
September 25, 2011 - Patient safety factors in children dying in a paediatric
intensive care unit (PICU): a case notes review … Patient safety factors in children dying in a paediatric intensive care
unit (PICU): a case notes review … https://psnet.ahrq.gov/issue/patient-safety-factors-children-dying-paediatric-intensive-care-unit-picu-case … https://psnet.ahrq.gov/issue/patient-safety-factors-children-dying-paediatric-intensive-care-unit-picu-case-notes-review … https://psnet.ahrq.gov/issue/patient-safety-factors-children-dying-paediatric-intensive-care-unit-picu-case-notes-review
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psnet.ahrq.gov/node/42507/psn-pdf
December 18, 2013 - Electronic error-reporting systems: a case study into the
impact on nurse reporting of medical errors … Electronic error-reporting systems: a case study into the impact
on nurse reporting of medical errors … https://psnet.ahrq.gov/issue/electronic-error-reporting-systems-case-study-impact-nurse-reporting-medical … https://psnet.ahrq.gov/issue/electronic-error-reporting-systems-case-study-impact-nurse-reporting-medical-errors … https://psnet.ahrq.gov/issue/electronic-error-reporting-systems-case-study-impact-nurse-reporting-medical-errors
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psnet.ahrq.gov/node/40350/psn-pdf
April 20, 2011 - Systemic vulnerabilities to suicide among veterans from
the Iraq and Afghanistan conflicts: review of case … Systemic vulnerabilities to suicide among veterans from the Iraq and
Afghanistan Conflicts: review of case … psnet.ahrq.gov/issue/systemic-vulnerabilities-suicide-among-veterans-iraq-and-afghanistan-
conflicts-review-case … psnet.ahrq.gov/issue/systemic-vulnerabilities-suicide-among-veterans-iraq-and-afghanistan-conflicts-review-case … psnet.ahrq.gov/issue/systemic-vulnerabilities-suicide-among-veterans-iraq-and-afghanistan-conflicts-review-case
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psnet.ahrq.gov/node/39695/psn-pdf
July 21, 2010 - The impact of the 80-hour work week on appropriate
resident case coverage. … The Impact of the 80-Hour Work Week on Appropriate Resident Case
Coverage. … https://psnet.ahrq.gov/issue/impact-80-hour-work-week-appropriate-resident-case-coverage
The newly proposed … However, this study found that
surgical residents maintained an adequate operative case volume over … https://psnet.ahrq.gov/issue/impact-80-hour-work-week-appropriate-resident-case-coverage
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/46458/psn-pdf
May 30, 2018 - Development of the Huddle Observation Tool for
structured case management discussions to improve
situation … Development of the Huddle Observation Tool for structured
case management discussions to improve situation … https://psnet.ahrq.gov/issue/development-huddle-observation-tool-structured-case-management-
discussions-improve-situation … https://psnet.ahrq.gov/issue/development-huddle-observation-tool-structured-case-management-discussions-improve-situation … https://psnet.ahrq.gov/issue/development-huddle-observation-tool-structured-case-management-discussions-improve-situation
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psnet.ahrq.gov/node/34701/psn-pdf
January 04, 2017 - Making the business case for patient safety.
January 4, 2017
Weeks WB, Bagian JP. … Making the business case for patient safety. Jt Comm J Qual Saf. 2003;29(1):51-4,
1. … https://psnet.ahrq.gov/issue/making-business-case-patient-safety
While the costs of medical error to … while acknowledging the ethical and societal
imperatives to improve safety, outline the “business case … https://psnet.ahrq.gov/issue/making-business-case-patient-safety
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psnet.ahrq.gov/node/38363/psn-pdf
February 23, 2009 - Critical care checklists, the Keystone Project, and the
Office for Human Research Protections: a case … Critical care checklists, the Keystone Project, and the Office for
Human Research Protections: A case … psnet.ahrq.gov/issue/critical-care-checklists-keystone-project-and-office-human-research-
protections-case … psnet.ahrq.gov/issue/critical-care-checklists-keystone-project-and-office-human-research-protections-case … psnet.ahrq.gov/issue/critical-care-checklists-keystone-project-and-office-human-research-protections-case
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psnet.ahrq.gov/node/39918/psn-pdf
October 13, 2010 - Reducing catheter-associated bloodstream infections in
the pediatric intensive care unit: business case … Reducing catheter-associated bloodstream infections in the pediatric
intensive care unit: Business case … /reducing-catheter-associated-bloodstream-infections-pediatric-intensive-care-
unit-business
This case-control … associated with
catheter–associated bloodstream infections, and uses these data to make the business case … psnet.ahrq.gov/primer/health-care-associated-infections
https://psnet.ahrq.gov/issue/making-business-case-patient-safety
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psnet.ahrq.gov/node/41414/psn-pdf
June 06, 2012 - Factors associated with reported preventable adverse
drug events: a retrospective, case-control study … Factors associated with reported preventable adverse drug events:
a retrospective, case-control study … ://psnet.ahrq.gov/issue/factors-associated-reported-preventable-adverse-drug-events-retrospective-
case-control-study … https://psnet.ahrq.gov/issue/factors-associated-reported-preventable-adverse-drug-events-retrospective-case-control-study … https://psnet.ahrq.gov/issue/factors-associated-reported-preventable-adverse-drug-events-retrospective-case-control-study
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psnet.ahrq.gov/node/41210/psn-pdf
January 03, 2017 - A case study on the safety impact of implementing smart
patient-controlled analgesic pumps at a tertiary … A case study on the safety impact of implementing smart patient-
controlled analgesic pumps at a tertiary … https://psnet.ahrq.gov/issue/case-study-safety-impact-implementing-smart-patient-controlled-analgesic … https://psnet.ahrq.gov/issue/case-study-safety-impact-implementing-smart-patient-controlled-analgesic-pumps-tertiary-care … https://psnet.ahrq.gov/issue/case-study-safety-impact-implementing-smart-patient-controlled-analgesic-pumps-tertiary-care
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psnet.ahrq.gov/node/47420/psn-pdf
January 01, 2019 - Gross negligence manslaughter and doctors: ethical
concerns following the case of Dr Bawa-Garba. … Gross negligence manslaughter and doctors: ethical concerns following the case
of Dr Bawa-Garba. … https://psnet.ahrq.gov/issue/gross-negligence-manslaughter-and-doctors-ethical-concerns-following-case … https://psnet.ahrq.gov/issue/gross-negligence-manslaughter-and-doctors-ethical-concerns-following-case-dr-bawa-garba … https://psnet.ahrq.gov/issue/gross-negligence-manslaughter-and-doctors-ethical-concerns-following-case-dr-bawa-garba
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psnet.ahrq.gov/node/41748/psn-pdf
April 05, 2013 - Factors contributing to all-cause 30-day readmissions: a
structured case series across 18 hospitals. … Factors contributing to all-cause 30-day readmissions: a
structured case series across 18 hospitals. … https://psnet.ahrq.gov/issue/factors-contributing-all-cause-30-day-readmissions-structured-case-series … This case series from the integrated Kaiser Permanente system found that nearly half of their 30-day … https://psnet.ahrq.gov/issue/factors-contributing-all-cause-30-day-readmissions-structured-case-series-across
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psnet.ahrq.gov/node/45751/psn-pdf
January 01, 2019 - doing-well-doing-good-evaluating-influence-patient-safety-performance-
hospital-financial
Experts have argued for a business case … A past PSNet perspective discussed efforts to promote the business case for patient
safety. … doing-well-doing-good-evaluating-influence-patient-safety-performance-hospital-financial
https://psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis … https://psnet.ahrq.gov/issue/business-case-quality-economic-analysis-michigan-keystone-patient-safety-program-icus … psnet.ahrq.gov/issue/hospital-safety-grade
https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.350_slideshow.ppt
June 01, 2015 - With Critical Implications
1
This presentation is based on the June 2015
AHRQ WebM&M Spotlight Case … of diagnostic errors
Describe system-based interventions that can help reduce diagnostic errors
3
Case … the left superficial femoral artery secondary to atherosclerotic peripheral arterial disease.
5
Case … From possible to probable to sure to wrong—premature closure and anchoring in a complicated case. … clinician's thought processes
Share uncertainty
Avoid words that frame case narrowly
19
Kassirer
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psnet.ahrq.gov/node/49683/psn-pdf
April 01, 2013 - and the case managers. … This tragic case reflects both positives and negatives about our health care system. … Case Rep Gastroenterol. 2007;1:15-20. [go to PubMed]
7. … Clozapine withdrawal-
emergent dystonias and dyskinesias: a case series. … Case report of withdrawal syndrome after olanzapine discontinuation.