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psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
March 19, 2019 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.
Citation Text:
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
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psnet.ahrq.gov/node/49744/psn-pdf
October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced
Hemolysis in a Patient With a Known Allergy
October 1, 2015
Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known
Allergy. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - A Double “Never Event”: Wrong Patient and Wrong Side.
Citation Text:
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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…
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psnet.ahrq.gov/node/49690/psn-pdf
September 01, 2013 - The Pains of Chronic Opioid Usage
September 1, 2013
Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
Case Objectives
Describe the appropriate initial assessment of patients with chronic non-cancer pain.
List the most comm…
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psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument
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January …
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psnet.ahrq.gov/node/49777/psn-pdf
December 01, 2016 - Suicidal Ideation in the Family Medicine Clinic
December 1, 2016
Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
Case Objectives
Recognize suicide as a major public health problem and the critical role of pri…
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - SPOTLIGHT CASE
Near Miss with Bedside Medications
Citation Text:
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - SPOTLIGHT CASE
False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.
Citation Text:
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - SPOTLIGHT CASE
Prolonged DKA in Pregnancy: A Case of Communication Breakdown.
Citation Text:
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…
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psnet.ahrq.gov/node/73899/psn-pdf
September 29, 2021 - Lost in Transitions of Care: Managing an Opioid-
Dependent Patient with Frequent Hospitalizations
September 29, 2021
Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent
Hospitalizations. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/lost-transitions-care…
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psnet.ahrq.gov/node/33613/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—II. The Duke Experience
May 1, 2005
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSNet
[internet]. 2005.
https://psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
Pe…
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psnet.ahrq.gov/node/33561/psn-pdf
September 15, 2024 - Never Events
September 15, 2024
Never Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/never-events
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 2024.
Backg…
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
June 01, 2005 - Related Resources
Diagnostic error in the critically ill: defining
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - Defining diagnosis as a process allows them to
apply all the things they know about how to improve processes
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psnet.ahrq.gov/perspective/safety-and-medical-education
December 01, 2013 - HS : Yes, we are still defining the "basic science" of diagnostic error but beginning to make some headway
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psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - August 2, 2010
The Science of Simulation in Healthcare: Defining and Developing Clinical
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psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
August 31, 2020 - Safety Across The Board
August 31, 2020
Defining Safety Across the Board
Safety Across
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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - HS : Yes, we are still defining the "basic science" of diagnostic error but beginning to make some headway
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psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
January 01, 2015 - In Conversation With… Mark Graban, MS, MBA
January 1, 2015
Also Read an Essay
Citation Text:
In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015…
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psnet.ahrq.gov/perspective/conversation-dave-debronkart
June 01, 2014 - In Conversation With… Dave deBronkart
June 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Dave deBronkart. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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