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psnet.ahrq.gov/issue/real-malady-marcel-proust-and-what-it-reveals-about-diagnostic-errors-medicine
September 27, 2022 - Commentary
The real malady of Marcel Proust and what it reveals about diagnostic errors in medicine.
Citation Text:
Douglas Y. The real malady of Marcel Proust and what it reveals about diagnostic errors in medicine. Med Hypotheses. 2016;90:14-8. doi:10.1016/j.mehy.2016.02.024.
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psnet.ahrq.gov/issue/building-cultures-high-reliability-lessons-high-reliability-organization-paradigm
September 05, 2018 - Review
Building cultures of high reliability: lessons from the high reliability organization paradigm.
Citation Text:
Sutcliffe KM. Building cultures of high reliability: lessons from the high reliability organization paradigm. Anesthesiol Clin. 2023;41(4):707-717. doi:10.1016/j.anclin.2…
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psnet.ahrq.gov/issue/revealing-disparities-health-care-workers-observations-discrimination-against-patients
April 12, 2006 - Book/Report
Revealing Disparities: Health Care Workers’ Observations of Discrimination Against Patients.
Citation Text:
Revealing Disparities: Health Care Workers’ Observations of Discrimination Against Patients. Fernandez H, Ayo-Vaughan M, Zephyrin LC, et al. New York, NY: The Commonwea…
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psnet.ahrq.gov/issue/effects-work-hour-reduction-residents-lives-systematic-review
March 02, 2011 - Review
Effects of work hour reduction on residents' lives: a systematic review.
Citation Text:
Fletcher KE, Underwood W, Davis SQ, et al. Effects of Work Hour Reduction on Residents’ Lives. JAMA. 2005;294(9):1088. doi:10.1001/jama.294.9.1088.
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psnet.ahrq.gov/issue/social-risk-health-inequity-and-patient-safety
September 28, 2022 - Commentary
Social risk, health inequity, and patient safety.
Citation Text:
Boisvert S. Social risk, health inequity, and patient safety. J Healthc Risk Manag. 2022;42(2):18-25. doi:10.1002/jhrm.21519.
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psnet.ahrq.gov/issue/patient-experience-source-understanding-origins-impact-and-remediation-diagnostic-errors
August 16, 2023 - Book/Report
Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors.
Citation Text:
Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors. Schlesinger M, Grob R, Gleason K, et al. Rock…
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psnet.ahrq.gov/issue/crisis-resource-management-evaluating-outcomes-multidisciplinary-team
December 23, 2011 - Study
Crisis resource management: evaluating outcomes of a multidisciplinary team.
Citation Text:
Jankouskas T, Bush MC, Murray B, et al. Crisis resource management: evaluating outcomes of a multidisciplinary team. Simul Healthc. 2007;2(2):96-101. doi:10.1097/SIH.0b013e31805d8b0d.
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psnet.ahrq.gov/issue/integrating-human-factors-research-and-surgery-review
August 02, 2015 - Review
Integrating human factors research and surgery: a review.
Citation Text:
Shouhed D, Gewertz BL, Wiegmann D, et al. Integrating human factors research and surgery: a review. Arch Surg. 2012;147(12):1141-1146. doi:10.1001/jamasurg.2013.596.
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psnet.ahrq.gov/issue/lessons-covid-war-investigative-report
March 09, 2022 - Book/Report
Lessons from the Covid War: An Investigative Report.
Citation Text:
Lessons from the Covid War: An Investigative Report. Covid Crisis Group. New York: Public Affairs; 2023. ISBN: 9781541703803.
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psnet.ahrq.gov/issue/application-human-error-theory-case-analysis-wrong-procedures
November 14, 2018 - Study
Application of human error theory in case analysis of wrong procedures.
Citation Text:
Duthie EA. Application of Human Error Theory in Case Analysis of Wrong Procedures. J Patient Saf. 2010;6(2):108-114. doi:10.1097/pts.0b013e3181de47f9.
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psnet.ahrq.gov/issue/safety-performance-and-satisfaction-outcomes-operating-room-literature-review
April 03, 2019 - Review
Emerging Classic
Safety, performance, and satisfaction outcomes in the operating room: a literature review.
Citation Text:
Joseph A, Bayramzadeh S, Zamani Z, et al. Safety, Performance, and Satisfaction Outcomes in the Operating Room: A Literature Review.…
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psnet.ahrq.gov/issue/checklist-improve-patient-safety-interventional-radiology
September 20, 2011 - Study
A checklist to improve patient safety in interventional radiology.
Citation Text:
Koetser ICJ, de Vries EN, van Delden OM, et al. A checklist to improve patient safety in interventional radiology. Cardiovasc Intervent Radiol. 2013;36(2):312-9. doi:10.1007/s00270-012-0395-z.
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psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps
February 24, 2011 - Study
Classic
Communication failures: an insidious contributor to medical mishaps.
Citation Text:
Sutcliffe K, Lewton E, Rosenthal M. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79(2):186-194.
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psnet.ahrq.gov/issue/lost-art-history-and-physical
May 08, 2013 - Commentary
The lost art of the history and physical.
Citation Text:
Natt B, Szerlip HM. The lost art of the history and physical. Am J Med Sci. 2014;348(5):423-5. doi:10.1097/MAJ.0000000000000326.
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psnet.ahrq.gov/issue/patient-safety-achieving-new-standard-care-0
March 29, 2007 - Book/Report
Classic
Patient Safety: Achieving a New Standard of Care.
Citation Text:
Patient Safety: Achieving a New Standard of Care. Institute of Medicine (US) Committee on Data Standards for Patient Safety, Aspden P, Corrigan JM, Wolcott J, Erickson SM, e…
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psnet.ahrq.gov/issue/principles-pediatric-patient-safety-reducing-harm-due-medical-care
May 22, 2019 - Organizational Policy/Guidelines
Principles of pediatric patient safety: reducing harm due to medical care.
Citation Text:
Mueller BU, Neuspiel DR, Fisher ERS, et al. Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care. Pediatrics. 2019;143(2):e20183649. doi:10.1542…
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psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classification-and-consequences
June 21, 2016 - Study
Classic
Cognitive errors in diagnosis: instantiation, classification, and consequences.
Citation Text:
Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation, classification, and consequences. Am J Med. 1989;86(4):433-41.
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psnet.ahrq.gov/issue/translating-electronic-health-record-based-patient-safety-algorithms-research-clinical
October 27, 2021 - Study
Translating electronic health record-based patient safety algorithms from research to clinical practice at multiple sites.
Citation Text:
Translating electronic health record-based patient safety algorithms from research to clinical practice at multiple sites. Zimolzak AJ, Singh H,…
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psnet.ahrq.gov/node/33644/psn-pdf
December 01, 2006 - Establishing a Safety Culture: Thinking Small
December 1, 2006
Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
Perspective
Safety cultures are the holy grail in any risky industry. Like all holy grails, th…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
November 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfusion Overload
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Source and Credits
This presentation is based on the November 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Manish S. Patel, MD, and Jeffrey L. Carson, MD, of UMDNJ−Robert Wood …