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psnet.ahrq.gov/web-mm/mark-my-limb
February 10, 2015 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/outpatient-zebra
January 23, 2020 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/check-twice-transport-once
March 15, 2023 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - If not explained adequately, family members may
carry out their own research and reach their own conclusions … The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/primer/checklists
September 15, 2024 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/primer/teamwork-training
September 15, 2024 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
September 15, 2024 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/primer/rapid-response-systems
July 18, 2024 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/primer/disclosure-errors
September 15, 2024 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
September 01, 2012 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - The RCA was completed, but the conclusions focused only on the individual anesthesiologist, and no interventions … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - gather accurate information and to integrate and interpret clinical data to draw accurate diagnostic conclusions … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/node/846915/psn-pdf
March 29, 2023 - Conclusions
In retrospect, given the acute presentation, this case could have been differently managed … The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/node/49445/psn-pdf
May 01, 2004 - The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/perspective/response-getting-root-matter-june-2005
June 01, 2005 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - If not explained adequately, family members may carry out their own research and reach their own conclusions … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
-
psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - The RCA was completed, but the conclusions focused only on the individual
anesthesiologist, and no interventions … The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not