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psnet.ahrq.gov/node/49773/psn-pdf
July 01, 2016 - Near Miss With Neonate
October 1, 2016
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/near-miss-neonate
The Case
A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm
dates. Early the next morning, intravenous oxy…
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psnet.ahrq.gov/node/49862/psn-pdf
May 01, 2019 - The Magnetic Deflection
May 1, 2019
Kanal E. The Magnetic Deflection. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/magnetic-deflection
The Case
A 68-year-old woman with a prior history of cerebrovascular accident and hypertension presented to the
hospital with new left-sided weakness and hypertensive urg…
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psnet.ahrq.gov/web-mm/lap-burn
March 01, 2018 - Lap Burn
Citation Text:
Ball K. Lap Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/informed-or-misled
April 24, 2018 - Informed or Misled?
Citation Text:
White SM. Informed or Misled?
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
…
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psnet.ahrq.gov/perspective/adverse-events-dentistry
December 22, 2020 - KH : Going back to our discussion about specific adverse events, we had talked about infection control
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psnet.ahrq.gov/issue/new-world-patient-safety-23rd-annual-samuel-jason-mixter-lecture
November 02, 2014 - Commentary
New world of patient safety. 23rd Annual Samuel Jason Mixter Lecture.
Citation Text:
Leape L. New world of patient safety: 23rd Annual Samuel Jason Mixter lecture. Arch Surg. 2009;144(5):394-8. doi:10.1001/archsurg.2009.78.
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DOI Google Schola…
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psnet.ahrq.gov/issue/devastatingly-human-analysis-registered-nurses-medication-error-accounts
June 27, 2018 - Study
Devastatingly human: an analysis of registered nurses' medication error accounts.
Citation Text:
Treiber LA, Jones JH. Devastatingly human: an analysis of registered nurses' medication error accounts. Qual Health Res. 2010;20(10):1327-42. doi:10.1177/1049732310372228.
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psnet.ahrq.gov/issue/many-faces-error-disclosure-common-set-elements-and-definition
December 16, 2009 - Study
Classic
The many faces of error disclosure: a common set of elements and a definition.
Citation Text:
Fein SP, Hilborne LH, Spiritus EM, et al. The many faces of error disclosure: a common set of elements and a definition. J Gen Intern Med. 2007;22(6):75…
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psnet.ahrq.gov/issue/more-words-interpersonal-communication-cognitive-bias-and-diagnostic-errors
March 11, 2013 - Commentary
'More than words' - interpersonal communication, cognitive bias and diagnostic errors.
Citation Text:
Dahm MR, Williams M, Crock C. ‘More than words’ – Interpersonal communication, cognitive bias and diagnostic errors. Patient Educ Couns. 2022;105(1):252-256. doi:10.1016/j.pec…
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psnet.ahrq.gov/issue/disclosing-adverse-events-patients-international-norms-and-trends
July 29, 2020 - Study
Disclosing adverse events to patients: international norms and trends.
Citation Text:
Wu AW, McCay L, Levinson W, et al. Disclosing Adverse Events to Patients: International Norms and Trends. J Patient Saf. 2017;13(1):43-49. doi:10.1097/PTS.0000000000000107.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.104_slideshow.ppt
September 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case September 2005
Double Trouble
Source and Credits
This presentation is based on the Sept. 2005
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Jerry H. Gurwitz, MD, University of…
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psnet.ahrq.gov/node/33802/psn-pdf
February 01, 2016 - Relationships Between Physician Professional
Satisfaction and Patient Safety
February 1, 2016
Friedberg MW. Relationships Between Physician Professional Satisfaction and Patient Safety. PSNet
[internet]. 2016.
https://psnet.ahrq.gov/perspective/relationships-between-physician-professional-satisfaction-and-patient-…
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psnet.ahrq.gov/node/50929/psn-pdf
February 26, 2020 - Discharged with IV antibiotics: When issues arise, who
manages the complications?
February 26, 2020
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the
complications? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-…
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psnet.ahrq.gov/node/49728/psn-pdf
March 01, 2015 - Medication Mix-Up: From Bad to Worse
March 1, 2015
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/medication-mix-bad-worse
The Case
A 69-year-old man with chronic kidney disease and essential hypertension was admitted to the hospital
with chest …
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - Missing Trauma
Citation Text:
Jurkovich GJ. Missing Trauma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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…
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - SPOTLIGHT CASE
The Missing Abscess: Radiology Reads in the Digital Era
Citation Text:
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/lost-transition
November 17, 2010 - SPOTLIGHT CASE
Lost in Transition
Citation Text:
Beach C. Lost in Transition. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/36317/psn-pdf
October 11, 2006 - Medication errors.
October 11, 2006
Hartigan-Go K. Int J Risk Safety Med. 2006;18(3):181-186.
https://psnet.ahrq.gov/issue/medication-errors
The author discusses causes of medication errors and drug safety and provides case examples of safe
medication practices from the Philippines.
https://psnet.ahrq.gov/issue/m…
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psnet.ahrq.gov/issue/near-miss-events-detected-using-emergency-department-trigger-tool
August 24, 2022 - Study
Near-miss events detected using the emergency department trigger tool.
Citation Text:
Griffey RT, Schneider RM, Todorov AA. Near-miss events detected using the emergency department trigger tool. J Patient Saf. 2023;19(2):59-66. doi:10.1097/pts.0000000000001092.
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