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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.350_slideshow.ppt
June 01, 2015 - ClinicalReasoning
18
Cognitive Awareness (2)
Cognitive awareness may also be improved through teamwork and case discussions
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psnet.ahrq.gov/node/49560/psn-pdf
April 01, 2008 - Too often, the timing of discussions to clarify patient preferences
only occurs in the last days of
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psnet.ahrq.gov/node/49401/psn-pdf
May 01, 2003 - Discussions with other faculty and the
clinic’s risk manager ensued in an effort to delineate the resident
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psnet.ahrq.gov/node/33864/psn-pdf
January 01, 2019 - These areas include counseling or
conducting difficult conversations, such as end-of-life discussions
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psnet.ahrq.gov/node/49754/psn-pdf
February 01, 2016 - atrium to cause paradoxical emboli).(
20-22) Regardless, this abnormal location should have triggered discussions
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psnet.ahrq.gov/node/33629/psn-pdf
March 01, 2006 - allow team
members to adjust their knowledge
Feedback is provided during group-work exercises and
discussions
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psnet.ahrq.gov/web-mm/do-me-favor
September 12, 2016 - "( 4,6 ) Open discussions about appropriate types of caregiving among colleagues in institutions is a
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - In subsequent discussions with both the patient and his wife about hormonal replacement, the patient
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psnet.ahrq.gov/web-mm/after-visit-confusion
August 21, 2007 - They may also provide patients with tailored information relevant to the clinical discussions that occurred
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psnet.ahrq.gov/node/35934/psn-pdf
February 24, 2011 - Learning from mistakes: factors that influence how
students and residents learn from medical errors.
February 24, 2011
Fischer M, Mazor KM, Baril JL, et al. Learning from mistakes. Factors that influence how students and
residents learn from medical errors. J Gen Intern Med. 2006;21(5):419-23.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/39213/psn-pdf
October 03, 2017 - Using patient safety morbidity and mortality conferences
to promote transparency and a culture of safety.
October 3, 2017
Szekendi MK, Barnard C, Creamer J, et al. Using patient safety morbidity and mortality conferences to
promote transparency and a culture of safety. Jt Comm J Qual Patient Saf. 2010;36(1):3-9.
h…
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psnet.ahrq.gov/node/38497/psn-pdf
July 13, 2009 - Social aspects of clinical errors: a discussion paper.
July 13, 2009
Richman J, Mason T, Mason-Whitehead E, et al. Social aspects of clinical errors. Int J Nurs Stud.
2009;46(8). doi:10.1016/j.ijnurstu.2009.01.006.
https://psnet.ahrq.gov/issue/social-aspects-clinical-errors-discussion-paper
This article engages wi…
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psnet.ahrq.gov/node/40705/psn-pdf
August 17, 2011 - Health Information Technology and Patient Safety: A
Dynamic Discussion.
August 17, 2011
Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; May 2011.
https://psnet.ahrq.gov/issue/health-information-technology-and-patient-safety-dynamic-discussion
This report from the Lucian Leape Institut…
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psnet.ahrq.gov/node/43714/psn-pdf
December 17, 2014 - ER doctor discusses role in Ebola patient's initial
misdiagnosis.
December 17, 2014
Dunklin R, Thompson S. Dallas Morning News. December 6, 2014.
https://psnet.ahrq.gov/issue/er-doctor-discusses-role-ebola-patients-initial-misdiagnosis
This news article reports on the widely publicized delayed diagnosis of Ebola a…
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psnet.ahrq.gov/node/33927/psn-pdf
June 23, 2015 - Errors, incidents and accidents in anaesthetic practice.
June 23, 2015
Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and
accidents in anaesthetic practice. Anaesth Intensive Care. 1993;21(5):506-19.
https://psnet.ahrq.gov/issue/errors-incidents-and-accidents-anae…
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psnet.ahrq.gov/node/34797/psn-pdf
October 06, 2015 - Adapting to new technologies in the operating room.
October 6, 2015
Cook RI, Woods DD. Adapting to New Technology in the Operating Room. Hum Factors. 2006;38(4):593-
613. doi:10.1518/001872096778827224.
https://psnet.ahrq.gov/issue/adapting-new-technologies-operating-room
New technology continues to offer great ad…
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psnet.ahrq.gov/node/36086/psn-pdf
June 14, 2011 - Sensemaking of patient safety risks and hazards.
June 14, 2011
Battles J, Dixon NM, Borotkanics RJ, et al. Sensemaking of patient safety risks and hazards. Health Serv
Res. 2006;41(4 Pt 2):1555-1575.
https://psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards
This commentary discusses the concept of …
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psnet.ahrq.gov/node/35127/psn-pdf
February 24, 2011 - Beyond the medical record: other modes of error
acknowledgment.
February 24, 2011
Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error
acknowledgment. J Gen Intern Med. 2005;20(5):404-9.
https://psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment
Thi…
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psnet.ahrq.gov/node/35832/psn-pdf
August 04, 2009 - The incorporation of patient safety into board certification
examinations.
August 4, 2009
Kachalia A, Johnson J, Miller ST, et al. The incorporation of patient safety into board certification
examinations. Acad Med. 2006;81(4):317-25.
https://psnet.ahrq.gov/issue/incorporation-patient-safety-board-certification-ex…
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psnet.ahrq.gov/node/34058/psn-pdf
September 29, 2017 - Research designs for studies evaluating the effectiveness
of change and improvement strategies.
September 29, 2017
Eccles M, Grimshaw J, Campbell M, et al. Research designs for studies evaluating the effectiveness of
change and improvement strategies. Qual Saf Health Care. 2003;12(1):47-52.
https://psnet.ahrq.gov/…