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psnet.ahrq.gov/node/36606/psn-pdf
January 31, 2007 - Cause of death: sloppy doctors.
January 31, 2007
Caplan J. Time. January 15, 2007.
https://psnet.ahrq.gov/issue/cause-death-sloppy-doctors
This article reports on an industry-supported initiative to reduce medication errors by encouraging
physicians to use electronic prescribing through a free Web-based tool.
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psnet.ahrq.gov/issue/case-safety-leadership-team-training-hospital-managers
August 31, 2011 - Study
A case for safety leadership team training of hospital managers.
Citation Text:
Singer SJ, Hayes J, Cooper JB, et al. A case for safety leadership team training of hospital managers. Health Care Manage Rev. 2011;36(2):188-200. doi:10.1097/HMR.0b013e318208cd1d.
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psnet.ahrq.gov/issue/liability-claims-and-costs-and-after-implementation-medical-error-disclosure-program
April 24, 2018 - Study
Classic
Liability claims and costs before and after implementation of a medical error disclosure program.
Citation Text:
Kachalia A, Kaufman SR, Boothman RC, et al. Liability claims and costs before and after implementation of a medical error disclosure …
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psnet.ahrq.gov/issue/adverse-event-reporting-practices-us-hospitals-results-national-survey
December 30, 2014 - Study
Adverse-event-reporting practices by US hospitals: results of a national survey.
Citation Text:
Farley DO, Haviland A, Champagne S, et al. Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care. 2008;17(6):416-23. doi:10.1136/qshc.20…
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psnet.ahrq.gov/node/41236/psn-pdf
March 29, 2018 - Speak Up video posters.
March 29, 2018
Oakbrook Terrace, IL: Joint Commission.
https://psnet.ahrq.gov/issue/speak-video-posters
The Speak Up video series encourages patients to actively participate in their care. Posters to complement
the video series, in both English and Spanish are available upon request.
http…
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psnet.ahrq.gov/node/36963/psn-pdf
September 12, 2011 - Health literacy and its influence on patient safety.
September 12, 2011
Ross J. Health Literacy and Its Influence on Patient Safety. Journal of PeriAnesthesia Nursing. 2007;22(3).
doi:10.1016/j.jopan.2007.03.005.
https://psnet.ahrq.gov/issue/health-literacy-and-its-influence-patient-safety
The author discusses the…
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psnet.ahrq.gov/issue/making-health-care-safer-ii-updated-critical-analysis-evidence-patient-safety-practices
March 13, 2013 - Book/Report
Classic
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices.
Citation Text:
Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer Ii: An Updated Critical Analysis Of The Evidence For…
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psnet.ahrq.gov/node/37645/psn-pdf
March 26, 2008 - Implementing a rapid response team: a practical guide.
March 26, 2008
Garretson S; Dip HE; Rauzi MB.
https://psnet.ahrq.gov/issue/implementing-rapid-response-team-practical-guide
This article discusses how one hospital implemented a rapid response team consisting of a hospitalist,
advance practice nurse, and respi…
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psnet.ahrq.gov/node/36793/psn-pdf
August 26, 2011 - Patient safety in Taiwan: a survey on orthopedic
surgeons.
August 26, 2011
Yang C-T, Chen H-H, Hou S-M. Patient safety in Taiwan: a survey on orthopedic surgeons. J Formos Med
Assoc. 2007;106(3):212-6.
https://psnet.ahrq.gov/issue/patient-safety-taiwan-survey-orthopedic-surgeons
The researchers surveyed Taiwanese…
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psnet.ahrq.gov/node/38979/psn-pdf
October 14, 2009 - Active learning: when is more better? The case of
resident physicians' medical errors.
October 14, 2009
Katz-Navon T; Naveh E; Stern Z.
https://psnet.ahrq.gov/issue/active-learning-when-more-better-case-resident-physicians-medical-errors
Establishing an active learning climate, in which resident physicians are enc…
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions
Citation Text:
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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Format:
Google Scholar BibTeX EndNote X3 X…
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psnet.ahrq.gov/node/866578/psn-pdf
August 28, 2024 - Don’t Wait to Collect an Accurate Weight: A Case of
Subtherapeutic Insulin Therapy
August 28, 2024
Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insul…
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - SPOTLIGHT CASE
Delirium or Dementia?
Citation Text:
Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7…
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psnet.ahrq.gov/node/34137/psn-pdf
February 06, 2018 - Anesthesia Patient Safety Foundation.
February 6, 2018
P.O. Box 6668, Rochester, MN 55903.
https://psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation
The Anesthesia Patient Safety Foundation's (APSF) mission is to ensure that no patient is harmed by the
effects of anesthesia. To achieve that mission, APSF s…
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psnet.ahrq.gov/node/37169/psn-pdf
October 06, 2011 - The safety journal: lessons learned with an error
reporting tool to stimulate systems thinking.
October 6, 2011
Singh R, Naughton B, Singh A, et al. The Safety Journal. J Patient Saf. 2007;3(3):135-141.
doi:10.1097/0b013e31814258db.
https://psnet.ahrq.gov/issue/safety-journal-lessons-learned-error-reporting-tool-s…
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psnet.ahrq.gov/node/40134/psn-pdf
February 17, 2011 - Sleep deprivation, elective surgical procedures, and
informed consent.
February 17, 2011
Nurok M, Czeisler CA, Lehmann LS. Sleep deprivation, elective surgical procedures, and informed
consent. N Engl J Med. 2010;363(27):2577-9. doi:10.1056/NEJMp1007901.
https://psnet.ahrq.gov/issue/sleep-deprivation-elective-surg…
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psnet.ahrq.gov/node/42145/psn-pdf
March 27, 2013 - Trends in adverse events over time: why are we not
improving?
March 27, 2013
Shojania KG, Thomas EJ. Trends in adverse events over time: why are we not improving? BMJ Qual Saf.
2013;22(4):273-7. doi:10.1136/bmjqs-2013-001935.
https://psnet.ahrq.gov/issue/trends-adverse-events-over-time-why-are-we-not-improving
Th…
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psnet.ahrq.gov/node/40858/psn-pdf
December 29, 2014 - Patients' and healthcare workers' perceptions of a patient
safety advisory.
December 29, 2014
Schwappach DLB, Frank O, Koppenberg J, et al. Patients' and healthcare workers' perceptions of a patient
safety advisory. Int J Qual Health Care. 2011;23(6):713-20. doi:10.1093/intqhc/mzr062.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/40464/psn-pdf
June 10, 2018 - Multiple latent failures align to allow a serious drug
interaction to harm a patient.
June 10, 2018
ISMP Medication Safety Alert! Acute care edition. May 5, 2011;16:1-3.
https://psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient
Detailing a case in which latent failures…
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psnet.ahrq.gov/node/37108/psn-pdf
October 04, 2011 - Electronic prescribing systems in pediatrics: the rationale
and functionality requirements.
October 4, 2011
Technology AA of PC on CI, Gerstle RS. Electronic prescribing systems in pediatrics: the rationale and
functionality requirements. Pediatrics. 2007;119(6):1229-31.
https://psnet.ahrq.gov/issue/electronic-pre…