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psnet.ahrq.gov/node/35307/psn-pdf
July 14, 2009 - Color coding to reduce errors.
July 14, 2009
Deboer S, Seaver M, Broselow J. Color coding to reduce errors. Am J Nurs. 2005;105(8):68-71.
https://psnet.ahrq.gov/issue/color-coding-reduce-errors
The authors present a color-coding system that helps estimate the weight of a child in a critical situation so
practition…
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psnet.ahrq.gov/node/37834/psn-pdf
September 08, 2010 - Patient Safety in Public Hospitals.
September 8, 2010
Victorian Auditor-General's Office. Melbourne, Australia: Victorian Government Printer; 2008. ISBN:
1921060689.
https://psnet.ahrq.gov/issue/patient-safety-public-hospitals
This report examined patient safety in public hospitals in the state of Victoria (Austra…
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psnet.ahrq.gov/issue/adverse-events-cough-and-cold-medications-after-market-withdrawal-products-labeled-infants
August 02, 2015 - Study
Adverse events from cough and cold medications after a market withdrawal of products labeled for infants.
Citation Text:
Shehab N, Schaefer MK, Kegler SR, et al. Adverse events from cough and cold medications after a market withdrawal of products labeled for infants. Pediatrics. 20…
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psnet.ahrq.gov/issue/physician-led-chart-audit-engaging-providers-fortifying-culture-safety
November 20, 2013 - Study
The "physician-led chart audit": engaging providers in fortifying a culture of safety.
Citation Text:
Gitkind MJ, Perla RJ, Manno M, et al. The "physician-led chart audit: " engaging providers in fortifying a culture of safety. J Patient Saf. 2014;10(1):72-9. doi:10.1097/PTS.0000…
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psnet.ahrq.gov/issue/changes-rates-autopsy-detected-diagnostic-errors-over-time-systematic-review
April 06, 2011 - Review
Classic
Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.
Citation Text:
Shojania KG, Burton EC, McDonald KM, et al. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003;2…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.287_slideshow.ppt
December 01, 2012 - Spotlight Case July 2008
Spotlight Case
The Lung Nodule That Refused To Grow
*
*
Source and Credits
This presentation is based on the December 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Alex A. Balekian, MD, MSHS, Keck School of Med…
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psnet.ahrq.gov/node/36417/psn-pdf
April 12, 2011 - Excess mortality caused by medical injury.
April 12, 2011
Meurer LN, Yang H, Guse CE, et al. Excess mortality caused by medical injury. Ann Fam Med.
2006;4(5):410-6.
https://psnet.ahrq.gov/issue/excess-mortality-caused-medical-injury
The authors describe a state-based review of discharge diagnoses to identify medi…
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psnet.ahrq.gov/node/42378/psn-pdf
August 15, 2013 - Surgical adverse events: a systematic review.
August 15, 2013
Anderson O, Davis R, Hanna GB, et al. Surgical adverse events: a systematic review. Am J Surg.
2013;206(2):253-62. doi:10.1016/j.amjsurg.2012.11.009.
https://psnet.ahrq.gov/issue/surgical-adverse-events-systematic-review
This systematic review estimates…
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psnet.ahrq.gov/node/34919/psn-pdf
February 25, 2009 - Changes in prognosis after the first postoperative
complication.
February 25, 2009
Silber JH, Rosenbaum PR, Trudeau ME, et al. Changes in prognosis after the first postoperative
complication. Med Care. 2005;43(2):122-31.
https://psnet.ahrq.gov/issue/changes-prognosis-after-first-postoperative-complication
The aut…
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psnet.ahrq.gov/node/33868/psn-pdf
October 01, 2018 - associated with preventable adverse drug events involving older patients in the
ambulatory setting were estimated
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psnet.ahrq.gov/node/36401/psn-pdf
December 22, 2010 - Epidemiology of medication-related adverse events in
nursing homes.
December 22, 2010
Handler S, Wright RM, Ruby CM, et al. Epidemiology of medication-related adverse events in nursing
homes. Am J Geriatr Pharmacother. 2006;4(3):264-72.
https://psnet.ahrq.gov/issue/epidemiology-medication-related-adverse-events-nu…
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psnet.ahrq.gov/node/43642/psn-pdf
November 05, 2014 - Exploring the Costs of Unsafe Care in the NHS: A Report
Prepared for the Department of Health.
November 5, 2014
London, UK: Frontier Economics Ltd; October 2014.
https://psnet.ahrq.gov/issue/exploring-costs-unsafe-care-nhs-report-prepared-department-health
This report provides an overview of evidence on preventabl…
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psnet.ahrq.gov/node/36685/psn-pdf
January 18, 2011 - Costs and benefits of an early-alert surveillance system
for hospital inpatients.
January 18, 2011
Marchetti A, Jacobs J, Young M, et al. Costs and benefits of an early-alert surveillance system for hospital
inpatients. Curr Med Res Opin. 2007;23(1):9-16.
https://psnet.ahrq.gov/issue/costs-and-benefits-early-alert…
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psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - (4
) found a pooled estimate of 147 suicides per 100,000 inpatient years (95% CI: 138-156) and the estimated
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psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - estimates put
medication error rates at 1 in 100 anesthetics.(2) Injury and death from such errors are estimated
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psnet.ahrq.gov/node/42648/psn-pdf
October 09, 2013 - The cost of poor blood specimen quality and errors in
preanalytical processes.
October 9, 2013
Green SF. The cost of poor blood specimen quality and errors in preanalytical processes. Clin Biochem.
2013;46(13-14):1175-9. doi:10.1016/j.clinbiochem.2013.06.001.
https://psnet.ahrq.gov/issue/cost-poor-blood-specimen-q…
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psnet.ahrq.gov/issue/patient-safety-external-beam-radiotherapy-guidelines-risk-assessment-and-analysis-adverse
March 15, 2017 - Study
Patient safety in external beam radiotherapy—guidelines on risk assessment and analysis of adverse error-events and near misses: introducing the ACCIRAD project.
Citation Text:
Malicki J, Bly R, Bulot M, et al. Patient safety in external beam radiotherapy - guidelines on risk asses…
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psnet.ahrq.gov/issue/factors-associated-system-level-activities-patient-safety-and-infection-control
January 15, 2009 - Study
Factors associated with system-level activities for patient safety and infection control.
Citation Text:
Fukuda H, Imanaka Y, Hirose M, et al. Factors associated with system-level activities for patient safety and infection control. Health Policy (New York). 2009;89(1):26-36. doi…
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psnet.ahrq.gov/issue/pediatric-patient-safety-events-during-hospitalization-approaches-accounting-institution
December 23, 2012 - Study
Pediatric patient safety events during hospitalization: approaches to accounting for institution-level effects.
Citation Text:
Slonim A, Marcin JP, Turenne W, et al. Pediatric patient safety events during hospitalization: approaches to accounting for institution-level effects. He…
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psnet.ahrq.gov/node/45047/psn-pdf
April 13, 2016 - Is misdiagnosis inevitable?
April 13, 2016
Page L. Medscape Business of Medicine. March 28, 2016.
https://psnet.ahrq.gov/issue/misdiagnosis-inevitable
This news article reports on the prevalence of diagnostic error and describes characteristics that contribute
to the problem, including insufficient clinician famil…