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psnet.ahrq.gov/node/74269/psn-pdf
January 19, 2022 - Safety culture, safety climate, and safety performance in
healthcare facilities: a systematic review.
January 19, 2022
Noor Arzahan IS, Ismail Z, Yasin SM. Safety culture, safety climate, and safety performance in healthcare
facilities: A systematic review. Safety Sci. 2022;147:105624. doi:10.1016/j.ssci.2021.10562…
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psnet.ahrq.gov/node/839812/psn-pdf
November 09, 2022 - Measuring psychological safety and local learning to
enable high reliability organisational change.
November 9, 2022
Cartland J, Green M, Kamm D, et al. Measuring psychological safety and local learning to enable high
reliability organisational change. BMJ Open Qual. 2022;11(4):e001757. doi:10.1136/bmjoq-2021-00175…
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psnet.ahrq.gov/node/46141/psn-pdf
May 17, 2017 - Ethical dilemma in missed melanoma: what to tell the
patient and other providers.
May 17, 2017
Vangipuram R, Horner ME, Menter A. Ethical dilemma in missed melanoma: What to tell the patient and
other providers. J Am Acad Dermatol. 2017;76(2):365-367. doi:10.1016/j.jaad.2016.08.030.
https://psnet.ahrq.gov/issue/et…
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psnet.ahrq.gov/node/47438/psn-pdf
June 02, 2019 - Developing an intervention to reduce harm in hospitalized
patients: patients and families in research.
June 2, 2019
Schenk EC, Bryant RA, Van Son CR, et al. Developing an Intervention to Reduce Harm in Hospitalized
Patients: Patients and Families in Research. J Nurs Care Qual. 2019;34(3):273-278.
doi:10.1097/NCQ.0…
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psnet.ahrq.gov/node/36680/psn-pdf
July 10, 2008 - Identifying diagnostic errors in primary care using an
electronic screening algorithm.
July 10, 2008
Singh H, Thomas EJ, Khan MM, et al. Identifying diagnostic errors in primary care using an electronic
screening algorithm. Arch Intern Med. 2007;167(3):302-308.
https://psnet.ahrq.gov/issue/identifying-diagnostic-e…
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psnet.ahrq.gov/node/34700/psn-pdf
January 04, 2017 - Reducing adverse drug events: lessons from a
breakthrough series collaborative.
January 4, 2017
Leape L, Kabcenell AI, Gandhi TK, et al. Reducing adverse drug events: lessons from a breakthrough
series collaborative. Jt Comm J Qual Improv. 2000;26(6):321-31.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-event…
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psnet.ahrq.gov/node/49822/psn-pdf
March 01, 2018 - Isolated Clot, Real Error
March 1, 2018
Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/isolated-clot-real-error
Case Objectives
Appreciate that errors are common in the management of venous thromboembolism disease.
Describe patients with venous thromboembolism i…
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - Do Not Disturb!
October 1, 2007
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/do-not-disturb
Case Objectives
Define professionalism.
Discuss behaviors associated with lack of professionalism.
Outline steps one should take if a significant breach of professionalism is …
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Delayed Diagnosis of Mesenteric Ischemia
Source and Credits
• This presentation is based on the August 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc
o AHRQ WebM&M…
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psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - The Wet Read
March 1, 2006
Arenson RL. The Wet Read. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/wet-read
Case Objectives
Appreciate the limitations of radiology resident emergency coverage.
Understand the rate of discrepancy between radiology resident preliminary reads and attending
radiologists' fina…
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/node/49786/psn-pdf
March 01, 2017 - Consequences of Medical Overuse
March 1, 2017
Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/consequences-medical-overuse
Case Objectives
Define overuse and overdiagnosis.
State how much of all care is estimated to be overuse.
Describe why the likelihood…
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psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
November 16, 2022 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.
Citation Text:
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.. PSNet [inter…
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psnet.ahrq.gov/node/72835/psn-pdf
March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy
March 10, 2021
In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family
Cente…
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psnet.ahrq.gov/node/60701/psn-pdf
July 22, 2020 - Prevalence and nature of medication errors and
medication-related harm following discharge from
hospital to community settings: a systematic review.
July 22, 2020
Alqenae FA, Steinke DT, Keers RN. Prevalence and nature of medication errors and medication-related
harm following discharge from hospital to community …
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psnet.ahrq.gov/node/38347/psn-pdf
May 24, 2015 - Using Telehealth to Improve Quality and Safety: Findings
from the AHRQ Portfolio.
May 24, 2015
Dixon BE, Hook JM, McGowan JJ, for AHRQ National Resource Center for Health IT. Rockville, MD:
Agency for Healthcare Research and Quality; December 2008. AHRQ Publication No. 09-0012-EF.
https://psnet.ahrq.gov/issue/usin…
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psnet.ahrq.gov/node/46113/psn-pdf
July 12, 2017 - Optimizing a Business Case for Safe Health Care: An
Integrated Approach to Safety and Finance.
July 12, 2017
Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for
Healthcare Improvement; 2017.
https://psnet.ahrq.gov/issue/optimizing-business-case-safe-health-care-in…
-
psnet.ahrq.gov/node/850172/psn-pdf
June 07, 2023 - Clinical nurse competence and its effect on patient safety
culture: a systematic review.
June 7, 2023
Zaitoun RA, Said NB, de Tantillo L. Clinical nurse competence and its effect on patient safety culture: a
systematic review. BMC Nurs. 2023;22(1):173. doi:10.1186/s12912-023-01305-w.
https://psnet.ahrq.gov/issue/c…
-
psnet.ahrq.gov/node/865967/psn-pdf
May 29, 2024 - Impact of diagnostic management team on patient time to
diagnosis and percent of accurate and clinically
actionable diagnoses.
May 29, 2024
Brashear J, Mize R, Laposata M, et al. Impact of diagnostic management team on patient time to diagnosis
and percent of accurate and clinically actionable diagnoses. Diagnosis…
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psnet.ahrq.gov/node/844777/psn-pdf
September 18, 2019 - Adapting cognitive task analysis to investigate clinical
decision making and medication safety incidents.
September 18, 2019
Russ AL, Militello LG, Glassman PA, et al. Adapting Cognitive Task Analysis to Investigate Clinical
Decision Making and Medication Safety Incidents. J Patient Saf. 2019;15(3):191-197.
doi:10…