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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 …
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psnet.ahrq.gov/node/33659/psn-pdf
October 01, 2007 - Making Just Culture a Reality: One Organization's
Approach
October 1, 2007
Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
Perspective
We've all been there...something goes wrong,…
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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…
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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:/…
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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…
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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…
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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…
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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.…
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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.…
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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…
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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
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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
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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…
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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…
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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
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - mandated that all hospitals publicly report care transition measure scores, and two other states are considering … record and requires that they be completed within 30 days of discharge.( 8 ) This is far too permissive, considering
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - record and requires that they be completed within 30 days of discharge.( 8 ) This is far too permissive, considering … mandated that all hospitals publicly report care transition measure scores, and two other states are considering
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - Leaders at institutions considering implementing remote telemetry monitoring must incorporate
perspectives
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psnet.ahrq.gov/web-mm/bloody-bp-cuff
June 21, 2016 - Considering the liability that a hospital may incur, cleansing or disposing of this equipment may result
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Answers to these questions provide a framework for considering solutions
based on patterns of behavior