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psnet.ahrq.gov/issue/rate-sepsis-hospitalizations-after-misdiagnosis-adult-emergency-department-patients-look
December 08, 2021 - Study
Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system.
Citation Text:
Horberg MA, Nassery …
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psnet.ahrq.gov/issue/antecedent-treat-and-release-diagnoses-prior-sepsis-hospitalization-among-adult-emergency
May 12, 2021 - Study
Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology.
Citation Text:
Nassery N, Horberg MA, …
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psnet.ahrq.gov/issue/mortality-risks-associated-emergency-admissions-during-weekends-and-public-holidays-analysis
September 02, 2020 - Study
Classic
Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records.
Citation Text:
Walker S, Mason A, Quan P, et al. Mortality risks associated with emergency admissions during weekend…
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psnet.ahrq.gov/issue/electronic-health-record-based-real-time-analytics-program-patient-safety-surveillance-and
May 19, 2018 - Study
An electronic health record–based real-time analytics program for patient safety surveillance and improvement.
Citation Text:
Classen D, Li M, Miller S, et al. An Electronic Health Record-Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement. Health Aff …
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psnet.ahrq.gov/issue/distinguishing-high-performing-low-performing-hospitals-severe-maternal-morbidity-focus
June 01, 2022 - Study
Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on quality and equity.
Citation Text:
Howell EA, Sofaer S, Balbierz A, et al. Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on q…
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psnet.ahrq.gov/issue/what-stops-hospital-clinical-staff-following-protocols-analysis-incidence-and-factors-behind
September 09, 2015 - Study
What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service.
Citation Text:
Shearer B, Marshal…
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psnet.ahrq.gov/issue/effect-health-information-exchange-recognition-medication-discrepancies-interrupted-when-data
November 16, 2022 - Study
Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial.
Citation Text:
Boockvar K, Ho W, Pruskowski J, et al. Effect of health information exchange on recogni…
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psnet.ahrq.gov/issue/missed-acute-myocardial-infarction-emergency-department-standardizing-measurement
May 12, 2021 - Study
Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method.
Citation Text:
Sharp AL, Baecker A, Nassery N, et al. Missed acute myocardial infarction in the emergency department–standardizing measurem…
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psnet.ahrq.gov/node/866869/psn-pdf
October 02, 2024 - Core Elements of Hospital Diagnostic Excellence (DxEx).
October 2, 2024
Core Elements of Hospital Diagnostic Excellence (DxEx). Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/core-elements-hospital-diagnostic-excellence-dxex
Diagnostic excellence is an expansion of the diagnostic error red…
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psnet.ahrq.gov/node/838147/psn-pdf
July 01, 2020 - Care Compare.
July 1, 2020
Centers for Medicare and Medicaid Services.
https://psnet.ahrq.gov/issue/care-compare
The Centers for Medicare & Medicaid Services (CMS) support transparency through the provision of
publicly available information on the quality of health care service in the United States. This portal en…
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psnet.ahrq.gov/node/60810/psn-pdf
August 12, 2020 - Hospitals Can Take Key Steps to Improve Safe Use of
Digital Systems.
August 12, 2020
Philadelphia, PA: Pew Charitable Trusts; July 21, 2020.
https://psnet.ahrq.gov/issue/hospitals-can-take-key-steps-improve-safe-use-digital-systems
Tracking problems with health information technology (Health IT) is an important st…
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psnet.ahrq.gov/node/38022/psn-pdf
August 27, 2008 - Hospitals try to calm doctors' outbursts: medical road
rage affecting patient safety, group says.
August 27, 2008
Kowalczyk L.
https://psnet.ahrq.gov/issue/hospitals-try-calm-doctors-outbursts-medical-road-rage-affecting-patient-
safety-group-says
This article describes how physician outbursts can affect patient …
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psnet.ahrq.gov/node/39091/psn-pdf
June 28, 2011 - Integration of prospective and retrospective methods for
risk analysis in hospitals.
June 28, 2011
Kessels-Habraken M, van der Schaaf TW, De Jonge J, et al. Integration of prospective and retrospective
methods for risk analysis in hospitals. Int J Qual Health Care. 2009;21(6):427-32.
doi:10.1093/intqhc/mzp043.
ht…
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psnet.ahrq.gov/node/44415/psn-pdf
October 28, 2015 - Medication discrepancies at pediatric hospital discharge.
October 28, 2015
Gattari TB, Krieger LN, Hu HM, et al. Medication Discrepancies at Pediatric Hospital Discharge. Hosp
Pediatr. 2015;5(8):439-45. doi:10.1542/hpeds.2014-0085.
https://psnet.ahrq.gov/issue/medication-discrepancies-pediatric-hospital-discharge
…
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psnet.ahrq.gov/node/40407/psn-pdf
October 04, 2011 - Insights into the climate of safety towards the prevention
of falls among hospital staff.
October 4, 2011
Black AA, Brauer SG, Bell RAR, et al. Insights into the climate of safety towards the prevention of falls
among hospital staff. J Clin Nurs. 2011;20(19-20):2924-30. doi:10.1111/j.1365-2702.2010.03535.x.
https:…
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psnet.ahrq.gov/node/39675/psn-pdf
January 19, 2011 - A 5-year analysis of rapid response system activation at
an in-hospital haemodialysis unit.
January 19, 2011
Galhotra S, Devita MA, Dew MA, et al. A 5-year analysis of rapid response system activation at an in-
hospital haemodialysis unit. Qual Saf Health Care. 2010;19(6):e38. doi:10.1136/qshc.2008.031666.
https:/…
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psnet.ahrq.gov/node/47466/psn-pdf
October 17, 2018 - ASHP guidelines on preventing medication errors in
hospitals.
October 17, 2018
Billstein-Leber M, Carrillo CJD, Cassano AT, et al. ASHP Guidelines on Preventing Medication Errors in
Hospitals. Am J Health-Syst Pharm. 2018;75(19):1493-1517. doi:10.2146/ajhp170811.
https://psnet.ahrq.gov/issue/ashp-guidelines-preven…
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psnet.ahrq.gov/node/861776/psn-pdf
January 31, 2024 - The Sunday story: when hospitals don't say sorry.
January 31, 2024
Rascoe A, Gorenstein D. National Public Radio. January 21, 2024.
https://psnet.ahrq.gov/issue/sunday-story-when-hospitals-dont-say-sorry
Openness about making mistakes is a challenge in health care due to fear of litigation and career damage.
This …
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psnet.ahrq.gov/node/60166/psn-pdf
March 25, 2020 - For 4 days, the hospital thought he had just pneumonia. It
was coronavirus.
March 25, 2020
Goldstein J, Salcedo A. For 4 days, the hospital thought he had just pneumonia. It was coronavirus. New
York Times. 2020;March 10.
https://psnet.ahrq.gov/issue/4-days-hospital-thought-he-had-just-pneumonia-it-was-coronavirus…
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psnet.ahrq.gov/node/40637/psn-pdf
October 03, 2012 - Surgical site infections in colon surgery: the patient, the
procedure, the hospital, and the surgeon.
October 3, 2012
Hübner M, Diana M, Zanetti G, et al. Surgical site infections in colon surgery: the patient, the procedure,
the hospital, and the surgeon. Arch Surg. 2011;146(11):1240-5. doi:10.1001/archsurg.2011.1…