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psnet.ahrq.gov/node/47370/psn-pdf
October 10, 2018 - Development of a conceptual map of negative
consequences for patients of overuse of medical tests
and treatments.
October 10, 2018
Korenstein D, Chimonas S, Barrow B, et al. Development of a Conceptual Map of Negative Consequences
for Patients of Overuse of Medical Tests and Treatments. JAMA Intern Med. 2018;178(1…
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psnet.ahrq.gov/node/34863/psn-pdf
June 12, 2007 - Internal Bleeding: The Truth Behind America's Terrifying
Epidemic of Medical Mistakes. Updated edition.
June 12, 2007
Wachter R, Shojania K. New York: Rugged Land; 2005. ISBN: 9781590710739.
https://psnet.ahrq.gov/issue/internal-bleeding-truth-behind-americas-terrifying-epidemic-medical-mistakes-
updated-edition
…
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psnet.ahrq.gov/node/34063/psn-pdf
September 18, 2011 - Risk factors for retained instruments and sponges after
surgery.
September 18, 2011
Gawande AA, Studdert DM, Orav J, et al. Risk factors for retained instruments and sponges after surgery.
N Engl J Med. 2003;348(3):229-35.
https://psnet.ahrq.gov/issue/risk-factors-retained-instruments-and-sponges-after-surgery
Th…
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psnet.ahrq.gov/node/837903/psn-pdf
August 24, 2022 - The impact of drug error reduction software on
preventing harmful adverse drug events in England: a
retrospective database study.
August 24, 2022
Sutherland A, Gerrard WS, Patel A, et al. The impact of drug error reduction software on preventing
harmful adverse drug events in England: a retrospective database stud…
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psnet.ahrq.gov/node/847535/psn-pdf
April 12, 2023 - Using the Generic Analysis Method to analyze sentinel
event reports across hospitals: a retrospective cross-
sectional study.
April 12, 2023
Baartmans MC, van Schoten SM, Smit BJ, et al. Using the Generic Analysis Method to analyze sentinel
event reports across hospitals: a retrospective cross-sectional study. J P…
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psnet.ahrq.gov/node/837693/psn-pdf
January 01, 2023 - Medication-related medical emergency team activations: a
case review study of frequency and preventability.
July 20, 2022
Levkovich BJ, Orosz J, Bingham G, et al. Medication-related Medical Emergency Team activations: a case
review study of frequency and preventability. BMJ Qual Saf. 2023;32(4):214-224. doi:10.1136…
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psnet.ahrq.gov/node/847736/psn-pdf
April 19, 2023 - Deficiencies in Emergent and Outpatient Care of a Patient
with Alcohol Use Disorder at the Richard L. Roudebush
VA Medical Center in Indianapolis, Indiana.
April 19, 2023
Washington, DC: VA Office of the Inspector General; March 29, 2023. Report no. 21-03680-80.
https://psnet.ahrq.gov/issue/deficiencies-emergent-a…
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psnet.ahrq.gov/node/74701/psn-pdf
January 26, 2022 - Non-conveyance of older adult patients and association
with subsequent clinical and adverse events after initial
assessment by ambulance clinicians: a cohort analysis.
January 26, 2022
Lederman J, Lindström V, Elmqvist C, et al. Non-conveyance of older adult patients and association with
subsequent clinical and ad…
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psnet.ahrq.gov/node/42932/psn-pdf
December 30, 2014 - SBAR improves communication and safety climate and
decreases incident reports due to communication errors
in an anaesthetic clinic: a prospective intervention study.
December 30, 2014
Randmaa M, Mårtensson G, Swenne CL, et al. SBAR improves communication and safety climate and
decreases incident reports due to com…
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psnet.ahrq.gov/node/72721/psn-pdf
February 10, 2021 - Supporting recovery after adverse events: an essential
component of surgeon well-being.
February 10, 2021
Berman L, Rialon KL, Mueller CM, et al. Supporting recovery after adverse events: an essential component
of surgeon well-being. J Pediatr Surg. 2021;56(5):833-838. doi:10.1016/j.jpedsurg.2020.12.031.
https://p…
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psnet.ahrq.gov/node/39387/psn-pdf
July 23, 2014 - Medication errors involving oral chemotherapy.
July 23, 2014
Weingart SN, Toro J, Spencer J, et al. Medication errors involving oral chemotherapy. Cancer.
2010;116(10):2455-2464. doi:10.1002/cncr.25027.
https://psnet.ahrq.gov/issue/medication-errors-involving-oral-chemotherapy
Widely publicized errors associated w…
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psnet.ahrq.gov/node/46455/psn-pdf
April 24, 2018 - ISMP Medication Safety Self Assessment for High-Alert
Medications.
April 24, 2018
Horsham, PA: Institute for Safe Medication Practices; 2017.
https://psnet.ahrq.gov/issue/ismp-medication-safety-self-assessment-high-alert-medications
High-alert medications have the potential to cause substantial patient harm if adm…
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psnet.ahrq.gov/node/74719/psn-pdf
February 02, 2022 - Failure to rescue following emergency surgery: a FRAM
analysis of the management of the deteriorating patient.
February 2, 2022
Sujan M, Bilbro N, Ross A, et al. Failure to rescue following emergency surgery: A FRAM analysis of the
management of the deteriorating patient. Appl Ergon. 2022;98:103608. doi:10.1016/j.a…
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psnet.ahrq.gov/node/46257/psn-pdf
October 11, 2017 - Outcomes of concurrent operations: results from the
American College of Surgeons' National Surgical Quality
Improvement Program.
October 11, 2017
Liu JB, Berian JR, Ban KA, et al. Outcomes of Concurrent Operations: Results From the American College
of Surgeons' National Surgical Quality Improvement Program. Ann Su…
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hcup-us.ahrq.gov/db/state/siddist/NewYork2005-2006SIDandSASD.pdf
January 01, 2005 - The 2005–2006 New York State Inpatient Databases (SID) and State Ambulatory
Surgery Databases (SASD) purchased prior to the year 2010 contain some duplicate
records. The duplicate records, while rare, occur in multiple hospitals across the State
of New York. The issue of the duplicate records, however, is limited, …
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/suicide-risk-in-adolescents-adults-and-older-adults-screening
May 20, 2014 - Rates of suicide attempts and deaths vary by sex, age, and race or ethnicity 1 . … per 100,000]) and those aged 55 to 59 years (47.8% [from 20.3 to 30.0 deaths per 100,000]). … rate in men increased by 39.6% (from 24.5 to 34.2 deaths per 100,000) 9 . … at a rate of 11.8 deaths per 100,000 persons 1 . … Deaths: Final Data for 2010. Natl Vital Stat Rep . 2013;61:1-117.
2.
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hcup-us.ahrq.gov/reports/factsandfigures/2007/exhibit5_3.jsp
January 01, 2007 - Four percent of stays resulted in in-hospital deaths and less than 1 percent were discharges against … Less than 1 percent of Medicaid, private insurance, and uninsured stays resulted in in-hospital deaths … For stays with Medicare as the primary payer, in-hospital deaths occurred in 4 percent of stays.
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psnet.ahrq.gov/node/44709/psn-pdf
November 18, 2016 - Prior studies have found that nearly 8% of deaths in
patients with major trauma may be preventable, … lost-information-during-handover-critically-injured-trauma-patients-mixed-methods-study
https://psnet.ahrq.gov/issue/classifying-errors-preventable-and-potentially-preventable-trauma-deaths
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psnet.ahrq.gov/node/38837/psn-pdf
June 28, 2011 - validity-selected-ahrq-patient-safety-indicators-based-va-national-surgical-quality
https://psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
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psnet.ahrq.gov/issue/closing-deaths-door-legal-innovations-end-epidemic-healthcare-harm
January 27, 2021 - Book/Report
Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm.
Citation Text:
Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm. Saks M, Landsman S. New York, NY: Oxford University Press; 2021. ISBN: 9780190667986.
…