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psnet.ahrq.gov/node/49692/psn-pdf
September 01, 2013 - A Picture Speaks 1000 Words
September 1, 2013
Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words
The Case
A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A aortic dissection
repair presented with chest p…
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psnet.ahrq.gov/node/49767/psn-pdf
August 21, 2016 - Falling Between the Cracks in the Software
August 21, 2016
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-between-cracks-software
The Case
A 61-year-old man with a history of osteoarthritis was scheduled for a total knee replacement. Prio…
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psnet.ahrq.gov/node/49511/psn-pdf
May 01, 2006 - Citrate Mix-Up
May 1, 2006
Weber RJ. Citrate Mix-Up. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/citrate-mix
The Case
A 36-year-old woman with multiple sclerosis, diabetes, and chronic renal failure was transferred from a
skilled nursing facility (SNF) to the hospital for treatment of an infection. On a…
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psnet.ahrq.gov/node/33641/psn-pdf
November 01, 2006 - Human Factors Engineering Can Teach You How to Be
Surprised Again
November 1, 2006
Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
Perspective
Certain phrases ar…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - PowerPoint Presentation
Spotlight
The Hazards of Distraction: Ticking All the EHR Boxes
*
Source and Credits
This presentation is based on the February 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
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psnet.ahrq.gov/node/33753/psn-pdf
August 22, 2013 - Update on Safety Culture
August 22, 2013
Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/update-safety-culture
Perspective
Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians
treat each other with r…
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psnet.ahrq.gov/primer/duty-hours-and-patient-safety
June 15, 2024 - Duty Hours and Patient Safety
Citation Text:
Duty Hours and Patient Safety. 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/print/pdf/node/842920
December 14, 2022 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Diagnostic Errors Case Studies
Curated Library
Web M&Ms
A Postpartum Woman with an Erroneous SARS-CoV-2 Test
Stephen A. Martin, MD, EdM, Gordon D. Schiff, MD, and Sanjat Kanjilal, MD, MPH | April 28, 2021
A pregnant patient was admitted for…
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psnet.ahrq.gov/node/49565/psn-pdf
July 01, 2008 - Wrong Route for Nutrients
July 1, 2008
Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wrong-route-nutrients
The Case
An 82-year-old man living in a skilled nursing facility (SNF) had not been eating or drinking well for about 6
months. He had lost weight and d…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.356_slideshow.ppt
September 01, 2015 - PowerPoint Presentation
Spotlight
Abdominal Pain in Early Pregnancy
This presentation is based on the September 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Charlie C. Kilpatrick, MD, Associate Professor of Obstetrics and Gynecology, Baylor …
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psnet.ahrq.gov/issue/looking-beyond-linkedin-case-excellence-and-academic-rigor-quality-and-safety-programs
January 04, 2019 - Commentary
Looking beyond LinkedIn: the case for excellence and academic rigor in quality and safety programs.
Citation Text:
Bearman G, Nori P. Looking beyond LinkedIn: the case for excellence and academic rigor in quality and safety programs. Am J Med. 2024;137(8):694-697. doi:10.1016/…
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psnet.ahrq.gov/issue/office-based-anesthesia-safety-and-outcomes
February 18, 2019 - Review
Office-based anesthesia: safety and outcomes.
Citation Text:
Shapiro FE, Punwani N, Rosenberg NM, et al. Office-Based Anesthesia. Anesth Analg. 2014;119(2):276-285. doi:10.1213/ane.0000000000000313.
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psnet.ahrq.gov/issue/simulation-obstetric-anesthesia
January 12, 2011 - Review
Simulation in obstetric anesthesia.
Citation Text:
Pratt SD. Focused review: simulation in obstetric anesthesia. Anesth Analg. 2012;114(1):186-90. doi:10.1213/ANE.0b013e3182377bbc.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML …
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psnet.ahrq.gov/issue/organizational-framework-reduce-professional-burnout-and-bring-back-joy-practice
February 03, 2016 - Commentary
An organizational framework to reduce professional burnout and bring back joy in practice.
Citation Text:
Swensen S, Shanafelt TD. An Organizational Framework to Reduce Professional Burnout and Bring Back Joy in Practice. Jt Comm J Qual Patient Saf. 2017;43(6):308-313. doi:10.…
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psnet.ahrq.gov/issue/medication-attributed-adverse-effects-placebo-groups-implications-assessment-adverse-effects
January 08, 2018 - Review
Medication-attributed adverse effects in placebo groups: implications for assessment of adverse effects.
Citation Text:
Rief W, Avorn J, Barsky AJ. Medication-attributed adverse effects in placebo groups: implications for assessment of adverse effects. Arch Intern Med. 2006;166(…
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psnet.ahrq.gov/issue/improving-care-transitions-optimizing-medication-reconciliation
June 17, 2014 - Commentary
Improving care transitions: optimizing medication reconciliation.
Citation Text:
Association AP, Pharmacists AS of H-S, Steeb D, et al. Improving care transitions: optimizing medication reconciliation. J Am Pharm Assoc (2003). 2012;52(4):e43-e52. doi:10.1331/JAPhA.2012.12527…
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psnet.ahrq.gov/issue/cutting-out-human-error
February 25, 2009 - Commentary
Cutting out human error.
Citation Text:
Feinmann J. Cutting out human error. BMJ. 2008;337:a2370. doi:10.1136/bmj.a2370.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/neurologist-and-patient-safety
October 04, 2011 - Review
The neurologist and patient safety.
Citation Text:
Glick TH. The neurologist and patient safety. Neurologist. 2005;11(3):140-149.
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psnet.ahrq.gov/issue/tracking-intraoperative-complications
April 30, 2014 - Study
Tracking intraoperative complications.
Citation Text:
Platz J, Hyman N. Tracking intraoperative complications. J Am Coll Surg. 2012;215(4):519-23. doi:10.1016/j.jamcollsurg.2012.06.001.
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psnet.ahrq.gov/issue/best-practices-patient-safety-2nd-global-ministerial-summit-patient-safety
June 27, 2018 - Book/Report
Best Practices in Patient Safety: 2nd Global Ministerial Summit on Patient Safety.
Citation Text:
Best Practices in Patient Safety: 2nd Global Ministerial Summit on Patient Safety. Federal Ministry of Health and World Health Organization: Bonn, Germany; March 2017.
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