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psnet.ahrq.gov/issue/outcomes-missed-diagnosis-pediatric-appendicitis-new-onset-diabetic-ketoacidosis-and-sepsis
September 29, 2021 - Study
Outcomes of missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis, and sepsis in five pediatric hospitals.
Citation Text:
Michelson KA, Bachur RG, Grubenhoff JA, et al. Outcomes of missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis, an…
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psnet.ahrq.gov/issue/integrative-review-current-evidence-relationship-between-hand-hygiene-interventions-and
February 22, 2023 - Review
An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections.
Citation Text:
Backman C, Zoutman DE, Marck PB. An integrative review of the current evidence on the relationship between h…
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psnet.ahrq.gov/issue/growth-mindset-approach-preparing-trainees-medical-error
August 19, 2020 - Commentary
A growth mindset approach to preparing trainees for medical error.
Citation Text:
Klein J, Delany C, Fischer MD, et al. A growth mindset approach to preparing trainees for medical error. BMJ Qual Saf. 2017;26(9):771-774. doi:10.1136/bmjqs-2016-006416.
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psnet.ahrq.gov/issue/characteristics-and-trends-medical-diagnostic-errors-united-states
December 14, 2022 - Study
Characteristics and trends of medical diagnostic errors in the United States.
Citation Text:
Ao HS, Matthews T. Characteristics and trends of medical diagnostic errors in the United States. Patient Safety. 2024;6(1):123603. doi:10.33940/001c.123603.
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psnet.ahrq.gov/issue/ai-promise-or-peril-patient-safety
July 20, 2022 - Commentary
AI: promise or peril for patient safety.
Citation Text:
Ullem BD, Hatlie MJ, Lounsbury O. AI: promise or peril for patient safety. J Patient Saf. 2025;21(1):34-37. doi:10.1097/pts.0000000000001301.
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psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-outputs-are-they-valid
November 25, 2009 - Study
Failure mode and effects analysis outputs: are they valid?
Citation Text:
Shebl NA, Franklin BD, Barber N. Failure mode and effects analysis outputs: are they valid? BMC Health Serv Res. 2012;12:150. doi:10.1186/1472-6963-12-150.
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psnet.ahrq.gov/issue/do-clinician-disruptive-behaviors-make-unsafe-environment-patients
September 16, 2020 - Study
Do clinician disruptive behaviors make an unsafe environment for patients?
Citation Text:
Dang D, Bae S-H, Karlowicz KA, et al. Do Clinician Disruptive Behaviors Make an Unsafe Environment for Patients? J Nurs Care Qual. 2016;31(2):115-123. doi:10.1097/NCQ.0000000000000150.
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psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation-stoelting-conference-2019-perioperative-deterioration
October 19, 2022 - Meeting/Conference Proceedings
The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue.
Citation Text:
Lin D, Peden CJ, Langness SM, et al. The Anesthesia Patient Safety Found…
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psnet.ahrq.gov/issue/optimizing-pediatric-patient-safety-emergency-care-setting
March 15, 2023 - Organizational Policy/Guidelines
Optimizing Pediatric Patient Safety in the Emergency Care Setting.
Citation Text:
Joseph MM, Mahajan P, Snow SK, et al. Optimizing Pediatric Patient Safety in the Emergency Care Setting. Pediatrics. 2022;150(5):e2022059673. doi:10.1542/peds.2022-059673.
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psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fiscal-2021
October 12, 2022 - Book/Report
Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.
Citation Text:
Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. Washington, DC: Veterans Affairs Office of Inspector General; 2…
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psnet.ahrq.gov/issue/healthcare-staff-wellbeing-burnout-and-patient-safety-systematic-review
November 13, 2024 - Review
Healthcare staff wellbeing, burnout, and patient safety: a systematic review.
Citation Text:
Hall LH, Johnson J, Watt I, et al. Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PLoS One. 2016;11(7):e0159015. doi:10.1371/journal.pone.0159015.
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psnet.ahrq.gov/issue/patient-patient-involvement-strategies-diagnostic-error-mitigation
April 24, 2018 - Review
The patient is in: patient involvement strategies for diagnostic error mitigation.
Citation Text:
McDonald KM, Bryce CL, Graber ML. The patient is in: patient involvement strategies for diagnostic error mitigation. BMJ Qual Saf. 2013;22 Suppl 2:ii33-ii39. doi:10.1136/bmjqs-2012-…
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psnet.ahrq.gov/issue/towards-safer-transitions-curriculum-teach-and-assess-hospital-hospice-handoffs
March 20, 2024 - Commentary
Towards safer transitions: a curriculum to teach and assess hospital-to-hospice handoffs.
Citation Text:
Darrah NJ, O'Connor NR. Toward Safer Transitions: A Curriculum to Teach and Assess Hospital-to-Hospice Handoffs. J Pain Symptom Manage. 2016;51(6):959-962.e2. doi:10.1016/j…
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psnet.ahrq.gov/issue/wrong-patient
December 23, 2008 - Commentary
Classic
The wrong patient.
Citation Text:
Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136(11):826-833.
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psnet.ahrq.gov/issue/strategies-learning-failure
September 25, 2024 - Commentary
Classic
Strategies for learning from failure.
Citation Text:
Edmondson A. Strategies of learning from failure. Harv Bus Rev. 2011;89(4):48-55, 137.
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psnet.ahrq.gov/issue/case-based-simulation-empowering-pediatric-residents-communicate-about-diagnostic-uncertainty
November 27, 2017 - Study
Case-based simulation empowering pediatric residents to communicate about diagnostic uncertainty.
Citation Text:
Olson ME, Borman-Shoap E, Mathias K, et al. Case-based simulation empowering pediatric residents to communicate about diagnostic uncertainty. Diagnosis (Berl). 2018;5(4)…
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psnet.ahrq.gov/issue/organisational-reporting-and-learning-systems-innovating-inside-and-outside-box
July 22, 2020 - Commentary
Organisational reporting and learning systems: innovating inside and outside of the box.
Citation Text:
Sujan M, Furniss D. Organisational reporting and learning systems: Innovating inside and outside of the box. Clin Risk. 2015;21(1):7-12. doi:10.1177/1356262215574203.
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psnet.ahrq.gov/issue/workarounds-intended-use-health-information-technology-narrative-review-human-factors
July 24, 2013 - Review
Emerging Classic
Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature.
Citation Text:
Patterson ES. Workarounds to Intended Use of Health Information Technology: A Narrative Review of…
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psnet.ahrq.gov/issue/crisis-health-care-call-action-physician-burnout
February 05, 2014 - Book/Report
A Crisis in Health Care: A Call to Action on Physician Burnout.
Citation Text:
A Crisis in Health Care: A Call to Action on Physician Burnout. Jha AK, Iliff AR, Chaoui AA, et al. Waltham, MA: Massachusetts Medical Society, Massachusetts Health and Hospital Association, Harvar…
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psnet.ahrq.gov/issue/conversations-diagnostic-uncertainty-and-its-management-among-pediatric-acute-care-physicians
March 17, 2021 - Study
Conversations on diagnostic uncertainty and its management among pediatric acute care physicians.
Citation Text:
Patel SJ, Ipsaro A, Brady PW. Conversations on diagnostic uncertainty and its management among pediatric acute care physicians. Hosp Pediatr. 2022;12(3):317-324. doi:10.…