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psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - model these skills and be vigilant to ensure that what they are passing on is accurate and performed correctly … .( 6 ) The reassurance offered to those in training by watching their faculty member correctly make diagnoses
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psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events
Citation Text:
Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Fo…
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psnet.ahrq.gov/node/47927/psn-pdf
July 31, 2019 - In-hospital mortality associated with the misdiagnosis or
unidentified site of infection at admission.
July 31, 2019
Abe T, Tokuda Y, Shiraishi A, et al. In-hospital mortality associated with the misdiagnosis or unidentified
site of infection at admission. Crit Care. 2019;23(1):202. doi:10.1186/s13054-019-2475-9.
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - interdisciplinary team
Electronic medical records with computerized provider order entry systems, when implemented correctly
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.143_slideshow.ppt
January 01, 2015 - Worried: “Will it heal correctly now?”
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psnet.ahrq.gov/issue/twelve-month-review-infusion-pump-near-miss-medication-and-dose-selection-errors-and-user
November 04, 2020 - Study
Twelve-month review of infusion pump near-miss medication and dose selection errors and user-initiated "good save" corrections: retrospective study.
Citation Text:
Waterson J, Al-Jaber R, Kassab T, et al. Twelve-month review of infusion pump near-miss medication and dose selection …
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psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
July 01, 2011 - Getting the (Right) Doctor, Right Away
Citation Text:
Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X…
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psnet.ahrq.gov/node/74700/psn-pdf
January 26, 2022 - Differential diagnosis checklists reduce diagnostic error
differentially: a randomised experiment.
January 26, 2022
Kämmer JE, Schauber SK, Hautz SC, et al. Differential diagnosis checklists reduce diagnostic error
differentially: a randomised experiment. Med Educ. 2021;55(10):1172-1182. doi:10.1111/medu.14596.
ht…
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psnet.ahrq.gov/node/60694/psn-pdf
January 01, 2021 - Reporting incidents involving the use of advanced
medical technologies by nurses in home care: a cross-
sectional survey and an analysis of registration data.
July 15, 2020
ten Haken I, Ben Allouch S, van Harten WH. Reporting incidents involving the use of advanced medical
technologies by nurses in home care: a cr…
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psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx
Spotlight
When the Lytes Go Out: A Case
of Inpatient Cardiac Arrest
Source and Credits
• This presentation is based on the September 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psne…
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psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - failures in network
infrastructure can result in delays when patient context or status is not
timely or correctly
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psnet.ahrq.gov/issue/effectiveness-surgical-safety-checklist-correcting-errors-literature-review-applying-reasons
January 10, 2018 - Review
Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model.
Citation Text:
Collins SJ, Newhouse R, Porter J, et al. Effectiveness of the surgical safety checklist in correcting errors: a literature review applying …
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psnet.ahrq.gov/issue/frequent-diagnostic-errors-cardiac-petct-due-misregistration-ct-attenuation-and-emission-pet
December 22, 2018 - Study
Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT attenuation and emission PET images: a definitive analysis of causes, consequences, and corrections.
Citation Text:
Gould L, Pan T, Loghin C, et al. Frequent diagnostic errors in cardiac PET/CT due to misre…
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psnet.ahrq.gov/web-mm/hazards-loading-doses
December 01, 2003 - individual clinician can also verify whether administering a loading dose is warranted and ordered correctly
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psnet.ahrq.gov/web-mm/which-end-which
February 09, 2011 - bowel obstruction caused by reversing the colon loops during laparoscopic surgery, is preventable by correctly
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psnet.ahrq.gov/node/836812/psn-pdf
March 30, 2022 - Strategies and Approaches for Investigating Patient
Safety Events
March 30, 2022
Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
Background
This primer provides a broad …
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psnet.ahrq.gov/node/37183/psn-pdf
October 06, 2011 - Frequent diagnostic errors in cardiac PET/CT due to
misregistration of CT attenuation and emission PET
images: a definitive analysis of causes, consequences,
and corrections.
October 6, 2011
Gould L, Pan T, Loghin C, et al. Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT
attenuation and …
-
psnet.ahrq.gov/node/837737/psn-pdf
July 27, 2022 - Patients' willingness and ability to identify and respond to
errors in their personal health records: mixed methods
analysis of cross-sectional survey data.
July 27, 2022
Lear R, Freise L, Kybert M, et al. Patients' willingness and ability to identify and respond to errors in their
personal health records: mixed m…
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psnet.ahrq.gov/node/61099/psn-pdf
November 04, 2020 - Twelve-month review of infusion pump near-miss
medication and dose selection errors and user-initiated
"good save" corrections: retrospective study.
November 4, 2020
Waterson J, Al-Jaber R, Kassab T, et al. Twelve-month review of infusion pump near-miss medication and
dose selection errors and user-Initiated "good…
-
psnet.ahrq.gov/node/47473/psn-pdf
December 05, 2018 - Holding out for an apology.
December 5, 2018
Holding out for an apology. BMJ. 2018;363:k3033. doi:10.1136/bmj.k3033.
https://psnet.ahrq.gov/issue/holding-out-apology
Patients who experience care complications are vulnerable to psychological consequences that can affect
their relationship with their clinical teams.…