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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - In contrast, Type 2 thinking is more deliberate and requires identifying features from a diagnostic category … present in the case and estimating the likelihood of such features in a particular disease.
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - Useful frameworks to examine the features and failures in diagnostic processing have been developed, … release it and consider alternatives”; anchoring – “the tendency to perceptually lock onto salient features
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psnet.ahrq.gov/issue/complications-surgeons-notes-imperfect-science
January 13, 2010 - Book/Report
Classic
Complications: A Surgeon's Notes on an Imperfect Science.
Citation Text:
Complications: A Surgeon's Notes on an Imperfect Science. Gawande A. New York, NY: Metropolitan Books; 2002. ISBN: 9780805063196.
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - Common features include enhancing patient and caregiver engagement, tracking and sharing safety data,
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - e.g., 2% of myocardial infarctions vs. 9% of strokes) ( 11 ), and especially by clinical presenting features … Bias or Heuristic Definition Anchoring The tendency to perceptually lock on to salient features
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psnet.ahrq.gov/issue/serious-hazards-transfusion-evaluating-dangers-wrong-patient-autologous-salvaged-blood
May 11, 2022 - Commentary
Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery.
Citation Text:
Uramatsu M, Maeda H, Mishima S, et al. Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in …
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psnet.ahrq.gov/issue/radonda-vaught-medication-safety-and-profession-pharmacy-steps-improve-safety-and-ensure
May 25, 2022 - Commentary
RaDonda Vaught, medication safety, and the profession of pharmacy: steps to improve safety and ensure justice.
Citation Text:
Lambert BL, Schiff GD. RaDonda Vaught, medication safety, and the profession of pharmacy: steps to improve safety and ensure justice. J Am Coll Clin Ph…
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psnet.ahrq.gov/issue/psychological-safety-intensive-care-unit-rounding-teams
May 05, 2021 - Study
Psychological safety in intensive care unit rounding teams.
Citation Text:
Diabes MA, Ervin JN, Davis BS, et al. Psychological safety in intensive care unit rounding teams. Ann Am Thorac Soc. 2021;18(6):1027-1033. doi:10.1513/annalsats.202006-753oc.
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psnet.ahrq.gov/issue/enhancing-safety-high-risk-operations-multilevel-analysis-role-mindful-organising-translating
January 26, 2022 - Study
Enhancing safety in high-risk operations: a multilevel analysis of the role of mindful organising in translating safety climate into individual safety behaviours.
Citation Text:
Renecle M, Curcuruto M, Gracia Lerín FJ, et al. Enhancing safety in high-risk operations: a multilevel a…
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psnet.ahrq.gov/issue/checklist-manifesto-how-get-things-right
February 06, 2018 - Book/Report
Classic
The Checklist Manifesto: How to Get Things Right.
Citation Text:
The Checklist Manifesto: How to Get Things Right. Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
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psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences
March 20, 2019 - Book/Report
Classic
Why Things Bite Back: Technology and the Revenge of Unintended Consequences.
Citation Text:
Why Things Bite Back: Technology and the Revenge of Unintended Consequences. Tenner E. New York, NY: Knopf; 1996. ISBN: 0679425632.
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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - As CPOE becomes a universally employed technology, pinpointing system features and implementation factors
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psnet.ahrq.gov/issue/do-hospitals-support-second-victims-collective-insights-patient-safety-leaders-maryland
May 11, 2016 - Study
Do hospitals support second victims? Collective insights from patient safety leaders in Maryland.
Citation Text:
Edrees HH, Morlock L, Wu AW. Do Hospitals Support Second Victims? Collective Insights From Patient Safety Leaders in Maryland. Jt Comm J Qual Saf. 2017;43(9):471-483. do…
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psnet.ahrq.gov/issue/assessing-safety-electronic-health-records-national-longitudinal-study-medication-related
July 29, 2020 - Study
Assessing the safety of electronic health records: a national longitudinal study of medication-related decision support.
Citation Text:
Holmgren J, Co Z, Newmark L, et al. Assessing the safety of electronic health records: a national longitudinal study of medication-related decisio…
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psnet.ahrq.gov/issue/addition-electronic-prescription-transmission-computerized-prescriber-order-entry-effect
March 13, 2019 - Study
Addition of electronic prescription transmission to computerized prescriber order entry: effect on dispensing errors in community pharmacies.
Citation Text:
Moniz TT, Seger AC, Keohane CA, et al. Addition of electronic prescription transmission to computerized prescriber order en…
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - and present with confusion, disorientation, lethargy, severe pain, severe distress, or with high-risk features … Most observers would agree that a 5-hour delay for a patient with high-risk features is unacceptable
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psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
August 21, 2005 - Immediate, rapidly evolving reactions: anaphylaxis, urticarial, or angioedema without systemic features
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - esophagogastroduodenoscopy [EGD]), vomiting/retching (Boerhaave syndrome), and foreign body ingestion, so usually there are features
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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - The selection of these features was driven by (1) areas addressed by the largest number of key studies
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - A Mistaken Dose of Naloxone?
December 18, 2019
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
The Case
A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up
appointment. He h…