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psnet.ahrq.gov/node/49709/psn-pdf
May 01, 2014 - Raise the Bar
May 1, 2014
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/raise-bar
The Case
A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The
patient was seen and evaluated by an anesthesiologist who was new to the cente…
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - Lost in Sign Out and Documentation
April 1, 2016
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
The Case
A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the
emergency physician, …
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psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - Milliliters vs. Milligrams
December 1, 2010
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
The Case
A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His
evaluation showed acu…
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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…
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psnet.ahrq.gov/node/49808/psn-pdf
October 01, 2017 - High-Risk Medications, High-Risk Transfers
October 1, 2017
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
The Case
A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - Timely diagnosis of esophageal perforation
Citation Text:
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/43643/psn-pdf
November 04, 2014 - Out-of-hospital medication errors among young children
in the United States, 2002–2012.
November 4, 2014
Smith MD, Spiller HA, Casavant MJ, et al. Out-of-hospital medication errors among young children in the
United States, 2002-2012. Pediatrics. 2014;134(5):867-76. doi:10.1542/peds.2014-0309.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/41223/psn-pdf
March 21, 2012 - High-profile investigations into hospital safety problems
in England did not prompt patients to switch providers.
March 21, 2012
Laverty AA, Smith PC, Pape UJ, et al. High-profile investigations into hospital safety problems in England
did not prompt patients to switch providers. Health Aff (Millwood). 2012;31(3):5…
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psnet.ahrq.gov/node/47082/psn-pdf
July 02, 2019 - Effect of systematic physician cross-checking on
reducing adverse events in the emergency department:
the CHARMED cluster randomized trial.
July 2, 2019
Freund Y, Goulet H, Leblanc J, et al. Effect of Systematic Physician Cross-checking on Reducing Adverse
Events in the Emergency Department: The CHARMED Cluster Ra…
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psnet.ahrq.gov/node/38612/psn-pdf
May 06, 2009 - Assessing controlled substance prescribing errors in a
pediatric teaching hospital: an analysis of the safety of
analgesic prescription practice in the transition from the
hospital to home.
May 6, 2009
Lee BH, Lehmann CU, Jackson E, et al. Assessing controlled substance prescribing errors in a pediatric
teaching …
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psnet.ahrq.gov/node/46424/psn-pdf
March 20, 2018 - Electronic triggers to identify delays in follow-up of
mammography: harnessing the power of big data in
health care.
March 20, 2018
Murphy DR, Meyer AND, Vaghani V, et al. Electronic Triggers to Identify Delays in Follow-Up of
Mammography: Harnessing the Power of Big Data in Health Care. J Am Coll Radiol. 2018;15(…
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psnet.ahrq.gov/node/41458/psn-pdf
June 19, 2012 - What stops hospital clinical staff from following
protocols? An analysis of the incidence and factors
behind the failure of bedside clinical staff to activate the
rapid response system in a multi-campus Australian
metropolitan healthcare service.
June 19, 2012
Shearer B, Marshall S, Buist MD, et al. What stops ho…
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psnet.ahrq.gov/node/39463/psn-pdf
February 10, 2015 - Mixed results in the safety performance of computerized
physician order entry.
February 10, 2015
Metzger J, Welebob E, Bates DW, et al. Mixed results in the safety performance of computerized physician
order entry. Health Aff (Millwood). 2010;29(4):655-663. doi:10.1377/hlthaff.2010.0160.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/47307/psn-pdf
December 12, 2018 - Are teaching hospitals treated fairly in the Hospital-
Acquired Condition Reduction Program?
December 12, 2018
Mohajer MA, Joiner KA, Nix DE. Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition
Reduction Program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.0000000000002399.
https://psnet.…
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psnet.ahrq.gov/node/44976/psn-pdf
February 14, 2017 - Do patients' disruptive behaviours influence the accuracy
of a doctor's diagnosis? A randomised experiment.
February 14, 2017
Schmidt HG, Van Gog T, Schuit SC, et al. Do patients' disruptive behaviours influence the accuracy of a
doctor's diagnosis? A randomised experiment. BMJ Qual Saf. 2017;26(1):19-23. doi:10.11…
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psnet.ahrq.gov/node/44643/psn-pdf
July 21, 2016 - Differing perceptions of safety culture across job roles in
the ambulatory setting: analysis of the AHRQ Medical
Office Survey on Patient Safety Culture.
July 21, 2016
Hickner J, Smith SA, Yount N, et al. Differing perceptions of safety culture across job roles in the
ambulatory setting: analysis of the AHRQ Medic…
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psnet.ahrq.gov/node/39604/psn-pdf
November 23, 2016 - Improving the patient, family, and clinician experience
after harmful events: the "When Things Go Wrong"
curriculum.
November 23, 2016
Bell SK, Moorman D, Delbanco T. Improving the patient, family, and clinician experience after harmful
events: the "when things go wrong" curriculum. Acad Med. 2010;85(6):1010-1017.…
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psnet.ahrq.gov/issue/lessons-event-reports
January 16, 2025 - Multi-use Website
Lessons from Event Reports.
Citation Text:
Lessons from Event Reports. Patient Safety Authority.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/node/45220/psn-pdf
June 08, 2016 - Medical Office Survey on Patient Safety Culture: 2016
User Comparative Database Report.
June 8, 2016
Famolaro T, Yount ND, Hare R, Thornton S, Sorra J. Rockville, MD: Agency for Healthcare Research and
Quality; May 2016. AHRQ Publication No. 16-0028-EF.
https://psnet.ahrq.gov/issue/medical-office-survey-patient-sa…
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psnet.ahrq.gov/node/43865/psn-pdf
May 01, 2015 - Computerised physician order entry-related medication
errors: analysis of reported errors and vulnerability
testing of current systems.
May 1, 2015
Schiff GD, Amato MG, Eguale T, et al. Computerised physician order entry-related medication errors:
analysis of reported errors and vulnerability testing of current sy…