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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - To say that the intern should have interpreted the image correctly while simultaneously confirming the
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psnet.ahrq.gov/node/866265/psn-pdf
July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to
Medication Error During Patient Transport
July 31, 2024
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During
Patient Transport. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…
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psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake
September 29, 2021 - Newspaper/Magazine Article
RaDonda Vaught says some system practices contributed to fatal mistake.
Citation Text:
RaDonda Vaught says some system practices contributed to fatal mistake. Clark C. MedPage Today. March 14, 2024.
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psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third-edition
May 18, 2016 - Book/Report
Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Third Edition.
Citation Text:
Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Third Edition. Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404066.
…
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psnet.ahrq.gov/issue/differential-diagnosis-checklists-reduce-diagnostic-error-differentially-randomised
September 23, 2020 - Study
Differential diagnosis checklists reduce diagnostic error differentially: a randomised experiment.
Citation Text:
Kämmer JE, Schauber SK, Hautz SC, et al. Differential diagnosis checklists reduce diagnostic error differentially: a randomised experiment. Med Educ. 2021;55(10):1172-1…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.76_slideshow.ppt
October 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case October 2004
Thin Air
Source and Credits
This presentation is based on the Oct. 2004
AHRQ WebM&M Spotlight Case in Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: David M. Gaba, MD, Stanford Univer…
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psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
February 26, 2025 - Are pressure ulcers not being discovered, or are they not being correctly staged so that people know
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psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - written in correct chart, but order sheets have the wrong name stamp Transcription Order correctly
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psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - The nurse correctly read the label in the presence of the surgeon, who may have been distracted, and
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psnet.ahrq.gov/node/846126/psn-pdf
March 09, 2023 - The nurse correctly read the label in the presence of the surgeon, who may have
been distracted, and
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psnet.ahrq.gov/issue/strategies-used-nurses-recover-medical-errors-academic-emergency-department-setting
September 26, 2016 - Study
Strategies used by nurses to recover medical errors in an academic emergency department setting.
Citation Text:
Henneman EA, Blank FSJ, Gawlinski A, et al. Strategies used by nurses to recover medical errors in an academic emergency department setting. Appl Nurs Res. 2006;19(2):70-…
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psnet.ahrq.gov/issue/problem-5-whys
July 19, 2023 - Commentary
The problem with the '5 whys.'
Citation Text:
Card AJ. The problem with '5 whys'. BMJ Qual Saf. 2017;26(8):671-677. doi:10.1136/bmjqs-2016-005849.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case
Citation Text:
Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US …
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - Airway Obstruction during Anterior Cervical Spine Surgery
Citation Text:
Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
…
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psnet.ahrq.gov/issue/medical-mistakes-are-more-likely-women-and-minorities
November 01, 2017 - Newspaper/Magazine Article
Medical mistakes are more likely in women and minorities.
Citation Text:
Medical mistakes are more likely in women and minorities. Szabo L. NBC News. January 15, 2024.
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Print
Download PD…
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psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
June 01, 2014 - Mixup Beyond the Medication Label
Citation Text:
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX EndNote …
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psnet.ahrq.gov/node/49788/psn-pdf
March 01, 2017 - Correct Treatment Plan for Incorrect Diagnosis: A
Pharmacist Intervention
March 1, 2017
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
The Case
A 48-year…
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psnet.ahrq.gov/issue/how-physicians-think-case-based-diagnostic-simulation-exercise
August 14, 2019 - Study
How physicians think: a case-based diagnostic simulation exercise.
Citation Text:
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.
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…
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psnet.ahrq.gov/issue/are-pathologists-self-aware-their-diagnostic-accuracy-metacognition-and-diagnostic-process
May 18, 2022 - Study
Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology.
Citation Text:
Clayton DA, Eguchi MM, Kerr KF, et al. Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology. Me…
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psnet.ahrq.gov/issue/designing-human-centered-ai-prevent-medication-dispensing-errors-focus-group-study
August 31, 2022 - Study
Designing human-centered AI to prevent medication dispensing errors: focus group study with pharmacists.
Citation Text:
Zheng Y, Rowell B, Chen Q, et al. Designing human-centered AI to prevent medication dispensing errors: focus group study with pharmacists. JMIR Form Res. 2023;7:e…