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psnet.ahrq.gov/node/49393/psn-pdf
April 01, 2003 - bowel obstruction caused by reversing the colon loops
during laparoscopic surgery, is preventable by correctly
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psnet.ahrq.gov/node/35868/psn-pdf
July 10, 2008 - Incidence, patterns, and prevention of wrong-site surgery.
July 10, 2008
Kwaan MR, Studdert DM, Zinner MJ, et al. Incidence, patterns, and prevention of wrong-site surgery. Arch
Surg. 2006;141(4):353-358.
https://psnet.ahrq.gov/issue/incidence-patterns-and-prevention-wrong-site-surgery
This AHRQ-supported study an…
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psnet.ahrq.gov/node/853773/psn-pdf
September 27, 2023 - back instructions and receiving confirmation, is recommended to
assure that all messages have been correctly
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psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - When the trigger correctly identifies an adverse event, causative factors can be determined and interventions
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psnet.ahrq.gov/issue/experimental-study-medical-error-explanations-do-apology-empathy-corrective-action-and
October 07, 2020 - Study
An experimental study of medical error explanations: do apology, empathy, corrective action, and compensation alter intentions and attitudes?
Citation Text:
Nazione S, Pace K. An Experimental Study of Medical Error Explanations: Do Apology, Empathy, Corrective Action, and Compensat…
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psnet.ahrq.gov/node/865529/psn-pdf
April 10, 2024 - A biased test kept thousands of Black people from getting
a kidney transplant.
April 10, 2024
Neergaard L. Associated Press. April 1, 2024.
https://psnet.ahrq.gov/issue/biased-test-kept-thousands-black-people-getting-kidney-transplant
Historical medical racism continues to harm patients today. This article discuss…
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psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
September 01, 2008 - are definitely lots of opportunities to use barcode technology to make sure that lab specimens are correctly … patient safety impact but definitely could increase the efficiency of the hospital if it's implemented correctly
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psnet.ahrq.gov/web-mm/mistaken-identity
December 18, 2014 - The Commentary Correctly identifying a patient seems like a straightforward task.
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psnet.ahrq.gov/node/33879/psn-pdf
May 01, 2019 - set them up for failure because we don't set our equipment boxes or our ambulance
stock cabinets up correctly … take a breath, before they engage in patient
care to gather the appropriate information and to do it correctly
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psnet.ahrq.gov/issue/experience-feedback-committees-way-implementing-root-cause-analysis-practice-hospital-medical
October 30, 2024 - Study
Experience feedback committees: a way of implementing a root cause analysis practice in hospital medical departments.
Citation Text:
François P, Lecoanet A, Caporossi A, et al. Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical …
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psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-corrective-action
November 27, 2018 - Book/Report
Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events.
Citation Text:
Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events. Oakbroo…
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psnet.ahrq.gov/node/73225/psn-pdf
May 05, 2021 - Black or 'other'? Doctors may be relying on race to make
decisions about your health.
May 5, 2021
Smith J, Spodak C. CNN. April 25, 2021.
https://psnet.ahrq.gov/issue/black-or-other-doctors-may-be-relying-race-make-decisions-about-your-health
Race-adjusted decision making tools perpetuate the potential for diagnos…
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psnet.ahrq.gov/node/60921/psn-pdf
September 16, 2020 - How physicians think: a case-based diagnostic simulation
exercise.
September 16, 2020
Gupta A, Quinn M, Saint S, et al. The variability in how physicians think: a casebased diagnostic simulation
exercise. Diagnosis (Berl). 2021;8(2):167-175. doi:10.1515/dx-2020-0010.
https://psnet.ahrq.gov/issue/how-physicians-thi…
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psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
April 24, 2024 - These errors were secondary to users either failing to correctly enter new patient information or failing
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psnet.ahrq.gov/issue/using-four-phased-unit-based-patient-safety-walkrounds-uncover-correctable-system-flaws
October 05, 2022 - Study
Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws.
Citation Text:
Taylor AM, Chuo J, Figueroa-Altmann A, et al. Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. Jt Comm J Qual Patient Saf. 2013;39…
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psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
September 01, 2008 - are definitely lots of opportunities to use barcode technology to make sure that lab specimens are correctly … patient safety impact but definitely could increase the efficiency of the hospital if it's implemented correctly
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psnet.ahrq.gov/node/49805/psn-pdf
September 01, 2017 - To say that the intern
should have interpreted the image correctly while simultaneously confirming the
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psnet.ahrq.gov/node/49675/psn-pdf
February 01, 2013 - the clinical evaluation is performed
well, appropriate tests are ordered, the tests are performed correctly … The clinician must see the test result, interpret it correctly, and determine an appropriate response
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psnet.ahrq.gov/node/49846/psn-pdf
November 01, 2018 - observing and directing the execution of tasks or activities and making certain
that everything is done correctly … observing and directing the execution of tasks or activities and
making certain that everything is done correctly
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psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - expose patients to increased bleeding risk.( 9 )
Make sure thrombophilia testing is indicated and correctly … Make sure thrombophilia testing is indicated and correctly performed
7.