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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49748/psn-pdf
    December 01, 2015 - Managing Ascites: Hazards of Fluid Removal December 1, 2015 Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal The Case A 50-year-old man with longstanding alcoholic cirrhosis presented to the emergency department (ED) w…
  2. psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
    December 14, 2022 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax Citation Text: Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37417/psn-pdf
    March 28, 2012 - Medication use leading to emergency department visits for adverse drug events in older adults. March 28, 2012 Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147(11):755-765. https://psnet.ahrq.gov/issue/med…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41568/psn-pdf
    April 05, 2013 - Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. April 5, 2013 Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf. 2012;21(9):737-745. doi:10.…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42067/psn-pdf
    March 18, 2013 - Methodological variations and their effects on reported medication administration error rates. March 18, 2013 McLeod MC, Barber N, Franklin BD. Methodological variations and their effects on reported medication administration error rates. BMJ Qual Saf. 2013;22(4):278-89. doi:10.1136/bmjqs-2012-001330. https://psne…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37940/psn-pdf
    June 16, 2010 - Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not? June 16, 2010 Weissman JS, Schneider EC, Weingart SN, et al. Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do n…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45231/psn-pdf
    February 14, 2017 - 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. February 14, 2017 Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. BMJ. 2016;352:h6781. doi:10.1136/bmj.h6781. https://psnet.…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39404/psn-pdf
    March 31, 2010 - Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. March 31, 2010 Cohen SP, Hayek SM, Datta S, et al. Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. Anesthesiology. 2010;112(3):711-8. doi:10.1097/ALN.0b013e3181cf892d. h…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73901/psn-pdf
    September 29, 2021 - Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors September 29, 2021 Searns JB, Williams MC, MacBrayne CE, et al. Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. Diagnosis (Berl). 2020;8(3):347-352. doi:10.1515/dx-2020-0032. https:/…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49777/psn-pdf
    December 01, 2016 - settings/primary-care/toolkit.(11,12) Importantly, suicidal ideation (defined as thinking about or considering
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49478/psn-pdf
    April 01, 2005 - The clinician considering the use of a contrast study in an at-risk patient must consider first the
  12. psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
    March 30, 2022 - Adverse Events, Near Misses, and Errors Citation Text: Adverse Events, Near Misses, and Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42639/psn-pdf
    November 08, 2013 - An intervention model that promotes accountability: peer messengers and patient/family complaints. November 8, 2013 Pichert JW, Moore IN, Karrass J, et al. An intervention model that promotes accountability: peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf. 2013;39(10):435-446. https://psn…
  14. psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
    February 01, 2007 - known to affect subconscious processing, such as advice to offset the availability heuristic by always considering
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49858/psn-pdf
    April 01, 2019 - Leaders at institutions considering implementing remote telemetry monitoring must incorporate perspectives
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42099/psn-pdf
    March 13, 2013 - Inpatient fall prevention programs as a patient safety strategy: a systematic review. March 13, 2013 Miake-Lye IM, Hempel S, Ganz DA, et al. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):390-396. doi:10.7326/0003-4819-158-5-201303051- 00005. …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73902/psn-pdf
    September 29, 2021 - Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome September 29, 2021 Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet]. 2021. https://psnet.ahrq.go…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74713/psn-pdf
    January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking January 26, 2022 Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking Disclosure of Relevant Financial Relationships: As a provider ac…
  19. psnet.ahrq.gov/issue/problem-checklists
    March 29, 2023 - Commentary The problem with checklists. Citation Text: Catchpole K, Russ S. The problem with checklists. BMJ Qual Saf. 2015;24(9):545-9. doi:10.1136/bmjqs-2015-004431. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49581/psn-pdf
    March 21, 2009 - Double Dosing, by the Rules March 21, 2009 Cohen H. Double Dosing, by the Rules. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/double-dosing-rules The Case A 65-year-old woman with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) was admitted to a medical unit during the night with wo…

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