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psnet.ahrq.gov/issue/complexity-team-training-what-we-have-learned-aviation-and-its-applications-medicine
December 09, 2009 - November 16, 2022
Just what the doctor ordered: missed ordering of venous thromboembolism
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psnet.ahrq.gov/node/836878/psn-pdf
April 27, 2022 - The Media’s Role in Patient Safety
April 27, 2022
Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/medias-role-patient-safety
Brief History of the Media Influencing Patient Safety
Despite studies raising questions about avoidable ha…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.17_slideshow.ppt
June 01, 2003 - PowerPoint Presentation
Spotlight Case June 2003
Missed Appendicitis
webmm.ahrq.gov
Source and Credits
This presentation is based on June 2003
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: James Adams, MD, Fei…
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psnet.ahrq.gov/node/33585/psn-pdf
March 15, 2025 - Radiation Safety
March 15, 2025
Radiation Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/radiation-safety
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 2025…
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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/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
June 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case June 2004
The Wrong Shot:
Error Disclosure
Source and Credits
This presentation is based on the June 2004
AHRQ WebM&M Spotlight Case in Pediatrics
CME credit is available through the Web site
See the full article at http://webmm.ahrq.gov
Commentary by: Thomas H. …
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psnet.ahrq.gov/node/33617/psn-pdf
August 01, 2005 - In Conversation with…Barbara A. Blakeney, MS, RN
August 1, 2005
In Conversation with…Barbara A. Blakeney, MS, RN. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
Editor's Note: Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses
Associa…
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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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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.323_slideshow.ppt
May 01, 2014 - PowerPoint Presentation
Spotlight
Medication Reconciliation With a Twist (or Dare We Say, a Patch?)
This presentation is based on the May 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Janice Kwan, MD, Department of Medicine, University of Tor…
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psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
October 30, 2024 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - The nurse documented the surgical counts as correct and “vag pack with Premarin® cream by
doctor, gauze
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psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx
Spotlight
A Missed Bowel Perforation – the Importance of
Diagnostic Reasoning
Source and Credits
• This presentation is based on the September 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/web…
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Type of Communication
Failure
Examples
Failure of Message
Transmission
Failure to inform
ICU doctor
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - More
than half of seniors who report taking prescription drugs have more than one doctor who prescribes
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psnet.ahrq.gov/node/72614/psn-pdf
March 01, 2021 - Gynaecology Team of Year 2007 (Royal College of Obstetricians and Gynaecologists,
United Kingdom)
Hospital Doctor
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - Enrico Coiera : Interruptions happen every day to every clinician, nurse, and doctor. … When I was a young doctor, when you newly joined a medical team, you would often be given a little worn … It should be pretty easy to train people that the doctor is putting the line in, so wait until that is
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psnet.ahrq.gov/node/49512/psn-pdf
May 01, 2006 - reporting.(1-3) Wrong-patient or wrong-site invasive
procedures may be uncommon but “for patient and doctor
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - She was told to see her doctor as soon as possible.
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psnet.ahrq.gov/node/33712/psn-pdf
June 01, 2011 - you practice on, how do you get that experience, and then
second, how much continuing education a doctor
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psnet.ahrq.gov/issue/healthcare-411-patient-safety-organizations-proposed-regulation
April 25, 2018 - Audiovisual
Healthcare 411: Patient Safety Organizations Proposed Regulation.
Citation Text:
Agency for Healthcare Research and Quality; AHRQ.
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