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psnet.ahrq.gov/node/39123/psn-pdf
April 30, 2014 - Incorrect surgical procedures within and outside of the
operating room.
April 30, 2014
Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room.
Arch Surg. 2009;144(11):1028-34. doi:10.1001/archsurg.2009.126.
https://psnet.ahrq.gov/issue/incorrect-surgical-proced…
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psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
April 01, 2010 - would be responsible for (i) implementing a comprehensive plan for measurement and reporting, (ii) identifying
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psnet.ahrq.gov/node/74120/psn-pdf
November 30, 2021 - Protecting the patient’s safety in this case involved
identifying and implementing measures to protect
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psnet.ahrq.gov/node/836976/psn-pdf
April 27, 2022 - passive stretch of the compartment should prompt
investigation for possible compartment syndrome.20
Identifying
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - Identifying errors and near-miss events can be challenging.
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - SPOTLIGHT CASE
Suicidal Ideation in the Family Medicine Clinic
Citation Text:
Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
…
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psnet.ahrq.gov/node/851099/psn-pdf
June 28, 2023 - Misconnection Leading to Arterial Thrombosis
June 28, 2023
Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
The Case
A 55-year-old man with chronic obstructive pulmonary disease (COPD) was brought by am…
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - SPOTLIGHT CASE
Right Regimen, Wrong Cancer: Patient Catches Medical Error
Citation Text:
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - Missed Opportunities for Suicide Risk Assessment
November 27, 2019
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…
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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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Format:
Google Scholar BibTeX EndN…
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - Challenges of Diabetes Management and Medication
Reconciliation
August 5, 2022
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
The Cases
Case #1: A 53-year-old man …
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psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Maternal Safety
Download
Share
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team
…
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psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
May 19, 2021 - SPOTLIGHT CASE
Postdischarge Follow-Up Phone Call
Citation Text:
Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Schol…
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psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - SPOTLIGHT CASE
Isolated Clot, Real Error
Citation Text:
Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX EndNote X3…
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - Challenges of Diabetes Management and Medication Reconciliation
Citation Text:
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
Copy Citation
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case April 2006
Is the “Surgical Personality” a Threat to Patient Safety?
Source and Credits
This presentation is based on the April 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary …
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - Identifying errors and near-miss events can be challenging.
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psnet.ahrq.gov/node/46766/psn-pdf
January 17, 2018 - What hinders the uptake of computerized decision
support systems in hospitals? A qualitative study and
framework for implementation.
January 17, 2018
Liberati EG, Ruggiero F, Galuppo L, et al. What hinders the uptake of computerized decision support
systems in hospitals? A qualitative study and framework for imple…
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psnet.ahrq.gov/node/847042/psn-pdf
April 05, 2023 - The relationship between patient safety culture and the
intentions of the nursing staff to report a near-miss event
during the COVID-19 crisis.
April 5, 2023
Idilbi N, Dokhi M, Malka-Zeevi H, et al. The relationship between patient safety culture and the intentions of
the nursing staff to report a near-miss event …
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psnet.ahrq.gov/node/866691/psn-pdf
September 11, 2024 - Unlocking the potential of free text in electronic health
records with large language models (LLM): enhancing
patient safety and consultation interactions.
September 11, 2024
Kumarapeli P, Haddad T, de Lusignan S. Unlocking the potential of free text in electronic health records
with large language models (LLM): e…