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psnet.ahrq.gov/node/866165/psn-pdf
June 19, 2024 - Actions for mitigating the negative effects of patient
participation in patient safety: a qualitative study.
June 19, 2024
Van der Voorden M, Franx A, Ahaus K. Actions for mitigating the negative effects of patient participation in
patient safety: a qualitative study. BMC Health Serv Res. 2024;24(1):700. doi:10.118…
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psnet.ahrq.gov/node/841474/psn-pdf
January 01, 2023 - Factors that affect opioid quality improvement initiatives
in primary care: insights from ten health systems.
December 14, 2022
Childs E, Tano CA, Mikosz CA, et al. Factors that affect opioid quality improvement initiatives in primary
care: insights from ten health systems. Jt Comm J Qual Patient Saf. 2023;49(1):26…
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psnet.ahrq.gov/node/34769/psn-pdf
March 28, 2005 - The Challenger Launch Decision: Risky Technology,
Culture, and Deviance at NASA.
March 28, 2005
Vaughan D. Chicago, IL: University of Chicago Press; 1996. ISBN 9780226851754.
https://psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa
A model of root cause analysis on a syste…
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psnet.ahrq.gov/node/849134/psn-pdf
May 17, 2023 - Adverse patient safety events during the COVID epidemic.
May 17, 2023
Yackel EE, Knowles RS, Jones CM, et al. Adverse patient safety events during the COVID epidemic. J
Patient Saf. 2023;19(5):340-345. doi:10.1097/pts.0000000000001129.
https://psnet.ahrq.gov/issue/adverse-patient-safety-events-during-covid-epidemic…
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psnet.ahrq.gov/node/72724/psn-pdf
February 10, 2021 - How satisfied are patients and surgeons with
telemedicine in orthopaedic care during the COVID-19
pandemic? A systematic review and meta-analysis.
February 10, 2021
Chaudhry H, Nadeem S, Mundi R. How Satisfied Are Patients and Surgeons with Telemedicine in
Orthopaedic Care During the COVID-19 Pandemic? A Systemati…
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psnet.ahrq.gov/web-mm/e-prescribing-e-error
February 03, 2021 - Improving patient safety by identifying side effects from introducing bar coding in medication administration
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - Identifying Risks to Patient Safety
The PCP, gastroenterologist, and endocrinologist did not fully consider
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - ventilator settings were applied, or the patient’s body habitus,
but this information would be useful in identifying
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psnet.ahrq.gov/node/850450/psn-pdf
June 14, 2023 - Call the clinic for additional background information …” Identifying the treating
outpatient physician
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.76_slideshow.ppt
October 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case October 2004
Thin Air
Source and Credits
This presentation is based on the Oct. 2004
AHRQ WebM&M Spotlight Case in Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: David M. Gaba, MD, Stanford Univer…
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psnet.ahrq.gov/node/33559/psn-pdf
December 15, 2024 - Medication Reconciliation
December 15, 2024
Medication Reconciliation. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/medication-reconciliation
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 safet…
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - Keys to detecting acute aortic dissection are a complete history (identifying the quality, severity,
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - These "ring downs" are necessarily brief, do not include identifying information (beyond patient age
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - mitigated through best practices in medication reconciliation , which is defined as the process of identifying
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - Identifying Risks to Patient Safety
The PCP, gastroenterologist, and endocrinologist did not fully
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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/node/49824/psn-pdf
March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous
Delay
March 1, 2018
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
The Case
A 35-year-old woman with no prior cardiac history calle…
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psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - Double Dosing, by the Rules
March 21, 2009
Cohen H. Double Dosing, by the Rules. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/double-dosing-rules
The Case
A 65-year-old woman with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) was
admitted to a medical unit during the night with wo…
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psnet.ahrq.gov/node/49448/psn-pdf
June 01, 2004 - Listen to the Family
June 1, 2004
Campbell D. Listen to the Family. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/listen-family
The Case
Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The
surgical resident examined the patient, an elderly woman with …
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psnet.ahrq.gov/node/49598/psn-pdf
February 01, 2010 - Medication Reconciliation Pitfalls
February 1, 2010
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
The Case
A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was
brought to the eme…