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psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
March 25, 2025 - department or get admitted to an inpatient facility, they typically have assessments and screenings that happen … worker or someone who is trained to see the person during their visit, that would be ideal, but it can’t happen
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psnet.ahrq.gov/perspective/suicide-prevention
March 24, 2025 - department or get admitted to an inpatient facility, they typically have assessments and screenings that happen … worker or someone who is trained to see the person during their visit, that would be ideal, but it can’t happen
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psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
May 11, 2014 - If similar practices exist in other ORs, additional accidents are waiting to happen.
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psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
March 01, 2015 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay
Citation Text:
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - "Superficial" Report Leads to "Deep" Problem
Citation Text:
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. 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/perspective/safety-across-board
August 31, 2020 - When that conversation can happen, you can then engage the community.
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - SPOTLIGHT CASE
Palliative Care: Comfort vs. Harm
Citation Text:
Jox RJ. Palliative Care: Comfort vs. Harm. 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/dangerous-detour
November 28, 2018 - risky as a person with a recent hip fracture unattended in a bathroom: both are accidents waiting to happen
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psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
December 01, 2009 - RW: How often does that happen in the life of a medium-sized hospital over a year?
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psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
December 01, 2009 - RW: How often does that happen in the life of a medium-sized hospital over a year?
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - Opioid Overdose as a Patient Safety Problem
Irene Berita Murimi, PhD, MA, and G. Caleb Alexander, MD, MS | May 22, 2017
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Citation Text:
Murimi IB, Alexander CG. Opioid Overdose as a Patient Safet…
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psnet.ahrq.gov/issue/good-care-slow-enough-be-able-pay-attention-primary-care-time-scarcity-and-patient-safety
August 04, 2015 - Study
"Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety.
Citation Text:
Satterwhite S, Nguyen M-LT, Honcharov V, et al. "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. J Gen Intern …
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psnet.ahrq.gov/web-mm/caution-interrupted
October 01, 2016 - Although much of the writing about emergency departments concerns biology, the most important things that happen
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psnet.ahrq.gov/node/33560/psn-pdf
June 15, 2024 - Disclosure of Errors
June 15, 2024
Disclosure of Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/disclosure-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed…
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psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
March 30, 2022 - Adverse Events, Near Misses, and Errors
Citation Text:
Adverse Events, Near Misses, and Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
January 01, 2024 - The Different Count Contributions to Retention
Differential Count Contributions in Retained Surgical Sponge Cases: Examination of Administrative Penalty
Cases from the California Department of Public Health (CDPH), Health and Safety Code Section 1280.1
Enforcement Reports from 2007-2014
A NoThing Left Behin…
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psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
January 31, 2024 - The Unhappy Patient Leaves Against Medical Advice.
Citation Text:
Nichols A. The Unhappy Patient Leaves Against Medical Advice.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/perspective/conversation-charles-vincent-mphil-phd
July 10, 2024 - In Conversation With… Charles Vincent, MPhil, PhD
June 1, 2012
Citation Text:
In Conversation With… Charles Vincent, MPhil, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
August 01, 2017 - The Evolution of Patient Safety in Surgery
Robert M. Wachter, MD | December 1, 2017
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Citation Text:
Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/perspective/safety-dentistry
August 01, 2016 - Safety In Dentistry
Rachel Badovinac Ramoni, DMD, ScD; Muhammad Walji, PhD; and Elsbeth Kalenderian, DDS, MPH, PhD | August 1, 2016
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Citation Text:
Ramoni R, Walji MF, Kalenderian E. Safety In De…