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psnet.ahrq.gov/issue/introduction-novel-patient-safety-advisory-evaluation-perceived-information-modified-qpp
April 05, 2023 - Study
Introduction of a novel patient safety advisory: evaluation of perceived information with a modified QPP questionnaire-a case-control study.
Citation Text:
Tubic B, Bånnsgård M, Gustavsson S, et al. Introduction of a novel patient safety advisory: evaluation of perceived informatio…
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psnet.ahrq.gov/issue/improving-departmental-psychological-safety-through-medical-school-wide-initiative
July 19, 2023 - Study
Improving departmental psychological safety through a medical school-wide initiative
Citation Text:
Porter-Stransky KA, Horneffer-Ginter KJ, Bauler LD, et al. Improving departmental psychological safety through a medical school-wide initiative. BMC Med Educ. 2024;24(1):800. doi:10.…
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psnet.ahrq.gov/issue/patient-safety-medical-imaging-joint-paper-european-society-radiology-esr-and-european
September 30, 2010 - Commentary
Patient safety in medical imaging: a joint paper of the European Society of Radiology (ESR) and the European Federation of Radiographer Societies (EFRS).
Citation Text:
Radiology ES of, Societies EF of R. Patient Safety in Medical Imaging: a joint paper of the European Society…
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psnet.ahrq.gov/issue/profiles-patient-safety-misplaced-femoral-line-guidewire-and-multiple-failures-detect-foreign
April 03, 2017 - Commentary
Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.
Citation Text:
Lum TE, Fairbanks RJ, Pennington EC, et al. Profiles in Patient Safety: Misplaced Femoral Line Guidewire and Multiple Failures t…
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psnet.ahrq.gov/issue/aviation-pediatric-surgery
January 12, 2022 - Commentary
From aviation to pediatric surgery.
Citation Text:
Arredondo Montero J, Bardají Pascual C. From aviation to pediatric surgery. Clin Pediatr (Phila). 2024;63(4):557-559. doi:10.1177/00099228231176631.
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DOI Google Scholar BibTeX EndNote X3 XML …
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psnet.ahrq.gov/issue/taking-challenge-improve-name-and-role-recognition-operating-room
July 12, 2023 - Review
Taking up the challenge to improve name and role recognition in the operating room.
Citation Text:
Thota B, Rabinowitz A, Guttman OT. Taking up the challenge to improve name and role recognition in the operating room. J Patient Saf. 2024;20(1):45-47. doi:10.1097/pts.00000000000011…
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psnet.ahrq.gov/issue/factors-associated-potentially-missed-diagnosis-appendicitis-emergency-department
December 16, 2020 - Study
Factors associated with potentially missed diagnosis of appendicitis in the emergency department.
Citation Text:
Mahajan P, Basu T, Pai C-W, et al. Factors associated with potentially missed diagnosis of appendicitis in the emergency department. JAMA Netw Open. 2020;3(3):e200612. d…
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psnet.ahrq.gov/issue/analysis-malpractice-claims-mammography-complex-issue
October 19, 2022 - Study
Analysis of malpractice claims in mammography: a complex issue.
Citation Text:
Fileni A, Magnavita N, Pescarini L. Analysis of malpractice claims in mammography: a complex issue. Radiol Med. 2009;114(4):636-44. doi:10.1007/s11547-009-0394-6.
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DO…
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psnet.ahrq.gov/issue/accuracy-radiographic-readings-emergency-department
November 18, 2016 - Study
Accuracy of radiographic readings in the emergency department.
Citation Text:
Petinaux B, Bhat R, Boniface K, et al. Accuracy of radiographic readings in the emergency department. Am J Emerg Med. 2011;29(1):18-25. doi:10.1016/j.ajem.2009.07.011.
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…
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psnet.ahrq.gov/issue/checkpoint-simple-tool-measure-surgical-safety-checklist-implementation-fidelity
December 06, 2023 - Study
CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity.
Citation Text:
Moyal-Smith R, Etheridge JC, Turley N, et al. CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity. BMJ Qual Saf. 2024;33(4):223-231. doi:10.1136…
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psnet.ahrq.gov/issue/factors-causing-variation-world-health-organization-surgical-safety-checklist-effectiveness
January 12, 2022 - Review
Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid scoping review.
Citation Text:
Wani MM, Gilbert JHV, Mohammed CA, et al. Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid sc…
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psnet.ahrq.gov/issue/contributing-factors-pediatric-ambulatory-diagnostic-process-errors-project-redde
November 30, 2022 - Study
Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.
Citation Text:
Dadlez NM, Adelman JS, Bundy DG, et al. Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE. Ped Qual Saf. 2020;5(3):e299-e305. doi:10.1097/pq9.…
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psnet.ahrq.gov/issue/frequency-diagnostic-errors-radiologic-reports-depends-patients-age
March 09, 2022 - Study
The frequency of diagnostic errors in radiologic reports depends on the patient's age.
Citation Text:
Diaz S, Ekberg O. The frequency of diagnostic errors in radiologic reports depends on the patient's age. Acta Radiol. 2010;51(8):934-8. doi:10.3109/02841851.2010.503192.
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psnet.ahrq.gov/issue/radiologist-initiated-double-reading-abdominal-ct-retrospective-analysis-clinical-importance
September 01, 2016 - Study
Radiologist-initiated double reading of abdominal CT: retrospective analysis of the clinical importance of changes to radiology reports.
Citation Text:
Lauritzen PM, Andersen JG, Stokke MV, et al. Radiologist-initiated double reading of abdominal CT: retrospective analysis of the c…
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psnet.ahrq.gov/issue/does-compliance-patient-safety-tasks-improve-and-sustain-when-radiotherapy-treatment
December 05, 2018 - Study
Does compliance to patient safety tasks improve and sustain when radiotherapy treatment processes are standardized?
Citation Text:
Simons P, Houben R, Benders J, et al. Does compliance to patient safety tasks improve and sustain when radiotherapy treatment processes are standardize…
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psnet.ahrq.gov/issue/helping-healthcare-teams-debrief-effectively-associations-debriefers-actions-and-participants
February 02, 2022 - Study
Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings.
Citation Text:
Kolbe M, Grande B, Lehmann-Willenbrock N, et al. Helping healthcare teams to debrief effectively: associations of debriefers’ a…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.290_slideshow.ppt
February 01, 2013 - occurred in which test results were not acted on
The death of a prominent physician’s daughter from cervical … cancer years after an abnormal PAP smear was not properly followed up
The Rory Staunton case in New
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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,…
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psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
April 01, 2008 - SPOTLIGHT CASE
A "Reflexive" Diagnosis in Primary Care
Citation Text:
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - SPOTLIGHT CASE
Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis
Citation Text:
Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. …