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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - Abnormal Volunteer Results
Citation Text:
Fernandez C. Abnormal Volunteer Results. 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/49794/psn-pdf
May 01, 2017 - Communication Error in a Closed ICU
May 1, 2017
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/communication-error-closed-icu
The Case
A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney
transplant), co…
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - The goals of this work are to advance just, effective perinatal care by identifying underlying factors … This isn't about identifying what an individual physician could have done better.
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psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - This isn't about identifying what an individual physician could have done better. … The goals of this work are to advance just, effective perinatal care by identifying underlying factors
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psnet.ahrq.gov/issue/association-between-waiting-times-and-short-term-mortality-and-hospital-admission-after
May 19, 2018 - Study
Classic
Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada.
Citation Text:
Guttmann A, Schull MJ, Vermeulen MJ, et al. Associatio…
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psnet.ahrq.gov/issue/interprofessional-clinical-event-debriefing-does-it-make-difference-attitudes-emergency
April 06, 2022 - Study
Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings.
Citation Text:
Rose SC, Ashari NA, Davies JM, et al. Interprofessional clinical event debriefing-does it make a difference? At…
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psnet.ahrq.gov/issue/team-based-approach-improving-medication-reconciliation-rates-family-medicine-residency
June 15, 2022 - Study
Team-based approach to improving medication reconciliation rates in family medicine residency clinics.
Citation Text:
Harper PG, Schafer KM, Van Riper K, et al. Team-based approach to improving medication reconciliation rates in family medicine residency clinics. J Am Pharm Assoc (…
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psnet.ahrq.gov/issue/comparative-economic-analyses-patient-safety-improvement-strategies-acute-care-systematic
November 07, 2012 - Review
Comparative economic analyses of patient safety improvement strategies in acute care: a systematic review.
Citation Text:
Etchells E, Koo M, Daneman N, et al. Comparative economic analyses of patient safety improvement strategies in acute care: a systematic review. BMJ Qual Saf.…
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psnet.ahrq.gov/issue/patient-safety-risks-associated-telecare-systematic-review-and-narrative-synthesis-literature
October 09, 2024 - Review
Patient safety risks associated with telecare: a systematic review and narrative synthesis of the literature.
Citation Text:
Guise V, Anderson JE, Wiig S. Patient safety risks associated with telecare: a systematic review and narrative synthesis of the literature. BMC Health Serv …
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psnet.ahrq.gov/issue/frequency-and-types-patient-reported-errors-electronic-health-record-ambulatory-care-notes
June 05, 2019 - Study
Classic
Frequency and types of patient-reported errors in electronic health record ambulatory care notes.
Citation Text:
Bell SK, Delbanco T, Elmore JG, et al. Frequency and types of patient-reported errors in electronic health record ambulatory care notes…
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psnet.ahrq.gov/issue/patients-perspectives-diagnostic-error-qualitative-study
February 10, 2012 - Study
Patients' perspectives of diagnostic error: a qualitative study.
Citation Text:
Sacco AY, Self QR, Worswick EL, et al. Patients' perspectives of diagnostic error: a qualitative study. J Patient Saf. 2021;17(8):e1759-e1773. doi:10.1097/pts.0000000000000642.
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psnet.ahrq.gov/issue/patient-misidentification-events-veterans-health-administration-comprehensive-review-context
November 24, 2021 - Study
Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.
Citation Text:
Kulju S, Morrish W, King LA, et al. Patient misidentification events in the Veterans Health Administration: a comprehensive …
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psnet.ahrq.gov/issue/doing-detective-work-find-cancer-how-are-non-specific-symptom-pathways-cancer-investigation
April 05, 2023 - Commentary
Doing 'detective work' to find a cancer: how are non-specific symptom pathways for cancer investigation organised, and what are the implications for safety and quality of care? A multisite qualitative approach.
Citation Text:
Black GB, Nicholson BD, Moreland J-A, et al. Doing …
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psnet.ahrq.gov/issue/prompting-rounding-teams-address-daily-best-practice-checklist-pediatric-intensive-care-unit
June 30, 2021 - Study
Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit.
Citation Text:
Cifra CL, Houston M, Otto A, et al. Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit. Jt Comm J Qual Patient …
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psnet.ahrq.gov/issue/wrong-side-thoracentesis-lessons-learned-root-cause-analysis
July 16, 2015 - Study
Wrong-side thoracentesis: lessons learned from root cause analysis.
Citation Text:
Miller K, Mims M, Paull DE, et al. Wrong-side thoracentesis: lessons learned from root cause analysis. JAMA Surg. 2014;149(8):774-9. doi:10.1001/jamasurg.2014.146.
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psnet.ahrq.gov/issue/standardizing-patient-safety-event-reporting-between-care-delivered-or-purchased-veterans
June 26, 2024 - Study
Standardizing patient safety event reporting between care delivered or purchased by the Veterans Health Administration (VHA).
Citation Text:
Rosen AK, Beilstein-Wedel E, Chan J, et al. Standardizing patient safety event reporting between care delivered or purchased by the Veterans …
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psnet.ahrq.gov/issue/characteristics-disease-specific-and-generic-diagnostic-pitfalls-qualitative-study
December 02, 2020 - Study
Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study.
Citation Text:
Schiff GD, Volodarskaya M, Ruan E, et al. Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study. JAMA Netw Open. 2022;5(1):e2144531. doi:10.10…
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psnet.ahrq.gov/issue/improving-general-practice-computer-systems-patient-safety-qualitative-study-key-stakeholders
October 16, 2012 - Study
Improving general practice computer systems for patient safety: qualitative study of key stakeholders.
Citation Text:
Avery A, Savelyich BSP, Sheikh A, et al. Improving general practice computer systems for patient safety: qualitative study of key stakeholders. Qual Saf Health Ca…
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psnet.ahrq.gov/issue/technology-based-closed-loop-tracking-improving-communication-and-follow-pathology-results
May 25, 2022 - Study
Technology-based closed-loop tracking for improving communication and follow-up of pathology results.
Citation Text:
Rajan SS, Baldwin J, Giardina TD, et al. Technology-based closed-loop tracking for improving communication and follow-up of pathology results. J Patient Saf. 2022;18…
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psnet.ahrq.gov/issue/unscheduled-return-visits-emergency-department-icu-admission-trigger-tool-diagnostic-error
December 02, 2020 - Study
Unscheduled return visits to the emergency department with ICU admission: a trigger tool for diagnostic error.
Citation Text:
Aaronson E, Jansson P, Wittbold K, et al. Unscheduled return visits to the emergency department with ICU admission: A trigger tool for diagnostic error. Am …