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psnet.ahrq.gov/node/35662/psn-pdf
June 25, 2010 - Debriefing after critical incidents for anaesthetic trainees.
June 25, 2010
Tan H. Debriefing after critical incidents for anaesthetic trainees. Anaesth Intensive Care. 2005;33(6):768-
72.
https://psnet.ahrq.gov/issue/debriefing-after-critical-incidents-anaesthetic-trainees
The author surveyed Australian anesthesi…
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psnet.ahrq.gov/node/49673/psn-pdf
December 01, 2012 - A Real Heartache
December 1, 2012
Polevoi SK. A Real Heartache. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/real-heartache
The Case
A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The
pain began at rest, and it radiated to his back and left axilla. He had…
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psnet.ahrq.gov/issue/patient-safety-and-staff-competence-managing-challenging-behavior-based-feedback-former
October 15, 2016 - Study
Patient safety and staff competence in managing challenging behavior based on feedback from former psychiatric patients.
Citation Text:
Tölli S, Kontio R, Partanen P, et al. Patient safety and staff competence in managing challenging behavior based on feedback from former psychiatr…
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psnet.ahrq.gov/node/36131/psn-pdf
September 29, 2010 - Emergent CSCW systems: the resolution and bandwidth
of workplaces.
September 29, 2010
Xiao Y, Seagull J. Emergent CSCW systems: the resolution and bandwidth of workplaces. Int J Med
Inform. 2007;76 Suppl 1:S261-6.
https://psnet.ahrq.gov/issue/emergent-cscw-systems-resolution-and-bandwidth-workplaces
The authors d…
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psnet.ahrq.gov/node/36139/psn-pdf
September 29, 2010 - Trends influencing the cost of care and patient safety.
September 29, 2010
Clark R. Trends influencing the cost of care and patient safety. Decision-making in five key areas can
improve clinical and economic performance. Health management technology. 2006;27(7):18, 20-1.
https://psnet.ahrq.gov/issue/trends-influenc…
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psnet.ahrq.gov/node/39562/psn-pdf
June 02, 2010 - Medical errors recovered by critical care nurses.
June 2, 2010
Dykes PC, Rothschild JM, Hurley A. Medical errors recovered by critical care nurses. J Nurs Adm.
2010;40(5):241-6. doi:10.1097/NNA.0b013e3181da408e.
https://psnet.ahrq.gov/issue/medical-errors-recovered-critical-care-nurses
This survey of critical care…
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psnet.ahrq.gov/node/38520/psn-pdf
September 19, 2016 - Inpatient suicide in a general hospital.
September 19, 2016
Cheng I-C, Hu F-C, Tseng M-CM. Inpatient suicide in a general hospital. Gen Hosp Psychiatry.
2009;31(2):110-5. doi:10.1016/j.genhosppsych.2008.12.008.
https://psnet.ahrq.gov/issue/inpatient-suicide-general-hospital
Suicide attempts by hospitalized patient…
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psnet.ahrq.gov/node/49619/psn-pdf
February 01, 2011 - Paradoxical Pulse
February 1, 2011
Roy CL. Paradoxical Pulse. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/paradoxical-pulse
The Case
An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful
pacemaker placement as an outpatient. The patient was restarted on …
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psnet.ahrq.gov/node/49409/psn-pdf
July 01, 2003 - Feeling No Pain
July 1, 2003
Bogner MS. Feeling No Pain. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/feeling-no-pain
The Case
A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the
patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…
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psnet.ahrq.gov/node/34623/psn-pdf
January 28, 2015 - Australian Commission on Safety and Quality in Health
Care.
January 28, 2015
Australian Commission for Safety and Quality in Health Care.
https://psnet.ahrq.gov/issue/australian-commission-safety-and-quality-health-care
Established in January 2006, the Commission leads and coordinates improvements in safety and qu…
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psnet.ahrq.gov/node/38138/psn-pdf
October 22, 2008 - Pharmacists and health information technology:
emerging issues in patient safety.
October 22, 2008
Fuji KT, Galt KA. Pharmacists and Health Information Technology: Emerging Issues in Patient Safety. HEC
Forum. 2008;20(3). doi:10.1007/s10730-008-9075-4.
https://psnet.ahrq.gov/issue/pharmacists-and-health-informatio…
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psnet.ahrq.gov/node/36938/psn-pdf
June 30, 2011 - The cost of pneumonia after acute stroke.
June 30, 2011
Katzan IL, Dawson NV, Thomas CL, et al. The cost of pneumonia after acute stroke. Neurology.
2007;68(22). doi:10.1212/01.wnl.0000263187.08969.45.
https://psnet.ahrq.gov/issue/cost-pneumonia-after-acute-stroke
Neglecting measures to prevent pneumonia after str…
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psnet.ahrq.gov/node/36111/psn-pdf
September 28, 2010 - Prescribing errors resulting in adverse drug events: how
can they be prevented?
September 28, 2010
Thürmann PA. Prescribing errors resulting in adverse drug events: how can they be prevented? Expert
Opin Drug Saf. 2006;5(4):489-93.
https://psnet.ahrq.gov/issue/prescribing-errors-resulting-adverse-drug-events-how-c…
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psnet.ahrq.gov/node/38901/psn-pdf
September 02, 2009 - Quantitative analysis of adverse events in neurosurgery.
September 2, 2009
Houkin K, Baba T, Minamida Y, et al. Quantitative analysis of adverse events in neurosurgery.
Neurosurgery. 2009;65(3):587-94; discussion 594. doi:10.1227/01.NEU.0000350860.59902.68.
https://psnet.ahrq.gov/issue/quantitative-analysis-adverse…
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psnet.ahrq.gov/node/34596/psn-pdf
February 17, 2009 - Disclosure: what works now and what can work even
better (part 3 of 3).
February 17, 2009
Chicago, IL: American Society of Healthcare Risk Management;
https://psnet.ahrq.gov/issue/disclosure-what-works-now-and-what-can-work-even-better-part-3-3
A guide for communicating throughout the disclosure process, thi…
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psnet.ahrq.gov/node/41517/psn-pdf
August 08, 2012 - What is preventable harm in healthcare? A systematic
review of definitions.
August 8, 2012
Nabhan M, Elraiyah T, Brown DR, et al. What is preventable harm in healthcare? A systematic review of
definitions. BMC Health Serv Res. 2012;12:128. doi:10.1186/1472-6963-12-128.
https://psnet.ahrq.gov/issue/what-preventable…
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psnet.ahrq.gov/node/39418/psn-pdf
March 31, 2010 - Take Charge of Your Hospital Stay to Avoid Medical
Mistakes.
March 31, 2010
Clarke S, Savard M. Good Morning America. ABC News. March 22, 2010.
https://psnet.ahrq.gov/issue/take-charge-your-hospital-stay-avoid-medical-mistakes
This television interview offers recommendations for patients to keep themselves safe wh…
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psnet.ahrq.gov/node/43492/psn-pdf
September 03, 2014 - Rethinking hospital restraints.
September 3, 2014
Parikh R. The Atlantic. August 18, 2014.
https://psnet.ahrq.gov/issue/rethinking-hospital-restraints
The inappropriate use of physical restraints on patients is considered a sentinel event. Although restraints
may be used to protect patients from harm, this magazin…
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psnet.ahrq.gov/node/45517/psn-pdf
March 01, 2017 - A lost voice.
March 1, 2017
Baker M. Seattle Times. February 10, 2017.
https://psnet.ahrq.gov/issue/lost-voice
Reporting on an incident involving a patient who died after a surgery, this news article discusses potential
contributing factors in the incident such as concurrent surgeries and failure to consider patie…
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psnet.ahrq.gov/node/35530/psn-pdf
March 02, 2010 - Health care provider use of private sector internal error-
reporting systems.
March 2, 2010
Roumm AR, Sciamanna CN, Nash DB. Health care provider use of private sector internal error-reporting
systems. Am J Med Qual. 2005;20(6):304-12.
https://psnet.ahrq.gov/issue/health-care-provider-use-private-sector-internal-e…