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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO
January 12, 2022
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In Conversation With.…
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psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
May 01, 2014 - In Conversation With… Didier Pittet, MD, MS
May 1, 2014
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Citation Text:
In Conversation With… Didier Pittet, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. …
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - Health Equity and Maternal Health
October 6, 2021
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Citation Text:
Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic
January 12, 2022
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Citation Text:
Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and…
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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - Lucy Savitz: We first need a concrete definition. What is a learning health system?
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Lucy Savitz: We first need a concrete definition. What is a learning health system?
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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - In fact, the original definition of a "critical incident" was basically an incident involving the potential
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psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - In fact, the original definition of a "critical incident" was basically an incident involving the potential
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - Pathologic Mistake
Citation Text:
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/hard-swallow
April 26, 2023 - Hard to Swallow
Citation Text:
Driver J. Hard to Swallow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/73650/psn-pdf
August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with
Recurrent Pneumothorax
August 25, 2021
Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent
Pneumothorax. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…
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psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
December 21, 2022 - In Conversation with…Troyen A. Brennan, MD, JD, MPH
December 1, 2005
Citation Text:
In Conversation with…Troyen A. Brennan, MD, JD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
…
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psnet.ahrq.gov/web-mm/dont-push
March 02, 2011 - Don't Push
Citation Text:
Meltzer HY. Don't Push. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/865374/psn-pdf
March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and
Challenges
March 27, 2024
Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
Introducti…
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psnet.ahrq.gov/node/49545/psn-pdf
September 01, 2007 - Coming Undone: Failure of Closure Device
September 1, 2007
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
The Case
A 65-year-old man underwent coronary angiography because of atypical exertional chest…
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psnet.ahrq.gov/node/40369/psn-pdf
April 13, 2011 - Safety culture in healthcare: a review of concepts,
dimensions, measures and progress.
April 13, 2011
Halligan M, Zecevic A. Safety culture in healthcare: a review of concepts, dimensions, measures and
progress. BMJ Qual Saf. 2011;20(4):338-43. doi:10.1136/bmjqs.2010.040964.
https://psnet.ahrq.gov/issue/safety-cul…
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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/node/39845/psn-pdf
November 02, 2010 - Incidence of medication errors and adverse drug events
in the ICU: a systematic review.
November 2, 2010
Wilmer A, Louie K, Dodek P, et al. Incidence of medication errors and adverse drug events in the ICU: a
systematic review. Qual Saf Health Care. 2010;19(5):e7. doi:10.1136/qshc.2008.030783.
https://psnet.ahrq.g…
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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 …
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psnet.ahrq.gov/node/838190/psn-pdf
September 28, 2015 - Use of an expedited review tool to screen for prior
diagnostic error in emergency department patients.
September 28, 2015
Hudspeth J, El-Kareh R, Schiff G. Use of an expedited review tool to screen for prior diagnostic error in
emergency department patients. Appl Clin Inform. 2015;06(04):619-628. doi:10.4338/aci-20…