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psnet.ahrq.gov/node/33879/psn-pdf
May 01, 2019 - In Conversation With… Jane Brice, MD, MPH
May 1, 2019
In Conversation With… Jane Brice, MD, MPH. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
Editor's note: Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University
of North Carolina. She…
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psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
March 01, 2019 - And how can we make sure this doesn't happen again? … And that often doesn't happen, or it happens in a flurry of white coats being led around without getting
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psnet.ahrq.gov/issue/how-can-specialist-investigation-agencies-inform-system-wide-learning-patient-safety
January 29, 2014 - Commentary
How can specialist investigation agencies inform system-wide learning for patient safety? A qualitative study of perspectives on the early years of the English Healthcare Safety Investigation Branch.
Citation Text:
Crompton A, Waring J, Macrae C, et al. How can specialist inv…
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psnet.ahrq.gov/issue/use-interactive-telephone-based-self-management-support-program-identify-adverse-events-among
June 11, 2010 - Study
Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients.
Citation Text:
Sarkar U, Handley MA, Gupta R, et al. Use of an interactive, telephone-based self-management support program to identify adverse ev…
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psnet.ahrq.gov/node/33816/psn-pdf
October 01, 2016 - ways illustrating that a patient is at risk for a bad
thing happening or a bad thing is starting to happen
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psnet.ahrq.gov/node/33881/psn-pdf
August 01, 2019 - In Conversation With… Erik Hollnagel, PhD
June 1, 2019
In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden)
as well as Visiting…
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psnet.ahrq.gov/node/33704/psn-pdf
December 01, 2010 - open and honest, I'd ask them if you could use it within the organization to help
ensure this doesn't happen
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psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
March 01, 2019 - And how can we make sure this doesn't happen again? … And that often doesn't happen, or it happens in a flurry of white coats being led around without getting
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psnet.ahrq.gov/node/35779/psn-pdf
July 20, 2010 - Our story.
July 20, 2010
King S. Our story. Pediatr Radiol. 2006;36(4):284-6.
https://psnet.ahrq.gov/issue/our-story
The author tells the story of medical errors that led to the death of her daughter Josie in 2001 and
discusses the activities her family has undertaken to prevent similar incidents from happening to…
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psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - The Wrong Shot: Error Disclosure
June 1, 2004
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
Case Objectives
Describe the rationale for disclosing harmful errors to patients.
Describe the specific information that patie…
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - SPOTLIGHT CASE
The Wrong Shot: Error Disclosure
Citation Text:
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Sch…
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psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
January 01, 2018 - We are testifying to things that didn't actually happen, physical exam findings that we didn't do, or
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psnet.ahrq.gov/node/36352/psn-pdf
April 14, 2011 - Patient expectations of fair complaint handling in
hospitals: empirical data.
April 14, 2011
Friele RD, Sluijs EM. Patient expectations of fair complaint handling in hospitals: empirical data. BMC
Health Serv Res. 2006;6:106.
https://psnet.ahrq.gov/issue/patient-expectations-fair-complaint-handling-hospitals-empir…
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psnet.ahrq.gov/node/45840/psn-pdf
February 08, 2017 - Implementation of the safety huddle.
February 8, 2017
Kylor C, Napier T, Rephann A, et al. Implementation of the Safety Huddle. Crit Care Nurse. 2016;36(6):80-
82.
https://psnet.ahrq.gov/issue/implementation-safety-huddle
The safety huddle is becoming common within health care practice as a way to inform clinician…
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psnet.ahrq.gov/node/37024/psn-pdf
January 02, 2017 - Every error a treasure: improving medication use with a
nonpunitive reporting system.
January 2, 2017
Lehmann DF, Page N, Kirschman K, et al. Every Error a Treasure: Improving Medication Use with a
Nonpunitive Reporting System. Jt Comm J Qual Patient Saf. 2016;33(7):401-407. doi:10.1016/s1553-
7250(07)33046-8.
ht…
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psnet.ahrq.gov/node/43739/psn-pdf
December 03, 2014 - Joshua’s Story.
December 3, 2014
Anderson-Wallace M, Denning R. Leeds, UK: Patient Stories; October 18, 2014.
https://psnet.ahrq.gov/issue/joshuas-story
Patient stories are a growing component of understanding the impact of medical errors on patients and
uncovering underlying causes. This video features an in-dept…
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psnet.ahrq.gov/node/44917/psn-pdf
November 30, 2016 - Canadian Incident Analysis Framework.
November 30, 2016
Incident Analysis Collaborating Parties. Edmonton, AB: Canadian Patient Safety Institute; 2012. ISBN:
9781926541440.
https://psnet.ahrq.gov/issue/canadian-incident-analysis-framework
Performing incident analysis can help organizations understand why adverse e…
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - We are testifying to things that didn't actually happen, physical exam findings that we didn't do, or
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psnet.ahrq.gov/node/44108/psn-pdf
November 06, 2015 - Service members are left in dark on health errors.
November 6, 2015
LaFraniere S. New York Times. April 19, 2015.
https://psnet.ahrq.gov/issue/service-members-are-left-dark-health-errors
Reporting on a case involving an overlooked test result that contributed to the death of a patient in the
military medical syste…
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psnet.ahrq.gov/node/34773/psn-pdf
March 08, 2017 - Medication Errors: The Nursing Experience.
March 8, 2017
Wolf ZR. Albany NY: Delmar Publishers; 1994. ISBN: 9780827362628.
https://psnet.ahrq.gov/issue/medication-errors-nursing-experience
In one of the first professional books to deal with medication error from the nursing perspective, Wolf
provides a comprehensi…