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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - SPOTLIGHT CASE
Delirium or Dementia?
Citation Text:
Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens
Citation Text:
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - SPOTLIGHT CASE
Failure to Report
Citation Text:
Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
February 22, 2023 - Annual Perspective
Improving Diagnostic Safety and Quality
Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD
| April 26, 2023
View more articles from the same authors.
Citation Text:
Al-Khafaji J, Lee M, Mossburg S. Improving Di…
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psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - Nothing Called Small Surgery
Citation Text:
Manske C. Nothing Called Small Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
January 01, 2016 - For example, if I don't diagnose something correctly in clinic, that patient may go on into the hospital
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psnet.ahrq.gov/primer/root-cause-analysis
March 30, 2022 - Root Cause Analysis
Citation Text:
Root Cause Analysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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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.
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psnet.ahrq.gov/primer/human-factors-engineering
December 15, 2024 - Human Factors Engineering
Citation Text:
Human Factors Engineering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/never-events
June 15, 2024 - Never Events
Citation Text:
Never Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety
Robert M. Wachter, MD | October 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wachter R. The Media: An Essential, If Sometimes Arbitrary, Pro…
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psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
December 14, 2022 - focuses on understanding why most healthcare delivery processes are successful and how they are performed correctly
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - SPOTLIGHT CASE
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
Citation Text:
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong
Medication
September 30, 2020
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
The Case
A 65-year-old woman co…
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - Systems Approach
September 15, 2024
Systems Approach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/systems-approach
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …
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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication
Citation Text:
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - SPOTLIGHT CASE
An Inadvertent Bolus of Norepinephrine.
Citation Text:
Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/node/33872/psn-pdf
January 01, 2018 - Update: Patient Engagement in Safety
January 1, 2018
Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/update-patient-engagement-safety
Annual Perspective 2018
Background
Patient engagement has become a cornerstone of patient safety. A Patient Saf…
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psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
September 01, 2016 - detect melanoma by using it to evaluate 93 photos of biopsy-proven melanoma.( 12 ) Disconcertingly, it correctly