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psnet.ahrq.gov/node/33641/psn-pdf
November 01, 2006 - Human Factors Engineering Can Teach You How to Be
Surprised Again
November 1, 2006
Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
Perspective
Certain phrases ar…
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psnet.ahrq.gov/web-mm/mark-my-limb
February 10, 2015 - Mark My Limb
Citation Text:
Jacott WE, O'Leary D. Mark My Limb. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
November 01, 2023 - Inadvertent Use of More Potent Acid Leads to Burn
Citation Text:
Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
December 07, 2020 - The independent dental practitioner is not going to be able to implement what a hospital will be able
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psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry
December 07, 2020 - The independent dental practitioner is not going to be able to implement what a hospital will be able
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psnet.ahrq.gov/web-mm/transfer-or-not-transfer
November 23, 2016 - SPOTLIGHT CASE
To Transfer or Not to Transfer
Citation Text:
Pines JM. To Transfer or Not to Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/49501/psn-pdf
February 03, 2006 - Lost in Transition
February 1, 2006
Beach C. Lost in Transition. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/lost-transition
Case Objectives
Provide an overview of transitions in continuously operating industries
Review cognitive error
Describe the complex dynamics of transitions in emergency care
Pro…
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psnet.ahrq.gov/node/33650/psn-pdf
May 01, 2007 - Patient Safety in the United Kingdom: Evolution and
Progress
May 1, 2007
Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evolution and Progress. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
Perspective
The dangers of health care in B…
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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - Infused, Not Ingested
November 1, 2005
Foley M. Infused, Not Ingested. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/infused-not-ingested
The Case
A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering
contrast, an unfamiliar task for this particular nurse. Rathe…
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psnet.ahrq.gov/web-mm/surprise-wire
July 15, 2020 - Surprise Wire
Citation Text:
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - Check the Anesthesia Machine
Citation Text:
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/issue/reportable-incidents
November 02, 2016 - Newspaper/Magazine Article
Reportable incidents.
Citation Text:
Barishansky RM, Glick DE. Reportable incidents. Establishing policies and procedures for when calls go wrong. EMS magazine. 2009;38(3):43-7.
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psnet.ahrq.gov/issue/obstetric-safety-and-quality
October 20, 2014 - Commentary
Obstetric safety and quality.
Citation Text:
Pettker CM, Grobman WA. Obstetric Safety and Quality. Obstet Gynecol. 2015;126(1):196-206. doi:10.1097/AOG.0000000000000918.
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psnet.ahrq.gov/issue/apology-errors-whose-responsibility
September 27, 2016 - Commentary
Apology for errors: whose responsibility?
Citation Text:
Leape L. Apology for errors: whose responsibility? Front Health Serv Manage. 2012;28(3):3-12.
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…
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psnet.ahrq.gov/issue/disclosing-harmful-pathology-errors-patients
May 18, 2022 - Commentary
Disclosing harmful pathology errors to patients.
Citation Text:
Dintzis SM, Gallagher TH. Disclosing harmful pathology errors to patients. Am J Clin Pathol. 2009;131(4):463-5. doi:10.1309/AJCPIO5SHDOD6URI.
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psnet.ahrq.gov/issue/ambulance-personnel-perceptions-near-misses-and-adverse-events-pediatric-patients
July 16, 2008 - Study
Ambulance personnel perceptions of near misses and adverse events in pediatric patients.
Citation Text:
Cushman JT, Fairbanks RJ, O'Gara KG, et al. Ambulance personnel perceptions of near misses and adverse events in pediatric patients. Prehosp Emerg Care. 2010;14(4):477-84. doi:…
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psnet.ahrq.gov/issue/how-discuss-errors-and-adverse-events-cancer-patients
April 01, 2010 - Commentary
How to discuss errors and adverse events with cancer patients.
Citation Text:
Yardley I, Yardley SJ, Wu AW. How to discuss errors and adverse events with cancer patients. Curr Oncol Rep. 2010;12(4):253-60. doi:10.1007/s11912-010-0109-0.
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DOI…
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psnet.ahrq.gov/issue/simulation-improve-patient-safety-getting-started
June 26, 2024 - Book/Report
Simulation to Improve Patient Safety: Getting Started.
Citation Text:
Deutsch ES, Bajaj K. Simulation To Improve Patient Safety: Getting Started. Rockville, MD: Agency for Healthcare Research and Quality; July 2024. Publication No. 24-0055.
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…
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psnet.ahrq.gov/issue/health-information-technology-leadership-panel-final-report
March 30, 2022 - Government Resource
Health Information Technology Leadership Panel: Final Report.
Citation Text:
Health Information Technology Leadership Panel: Final Report. Lewin Group: Falls Church, VA; March 2005.
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psnet.ahrq.gov/node/49520/psn-pdf
September 01, 2006 - DNR in the OR and Afterwards
September 1, 2006
Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
The Case
An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and
suffered a fractured femur. After initial eval…