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psnet.ahrq.gov/issue/report-short-life-working-group-reducing-medication-related-harm
September 09, 2015 - Book/Report
The Report of the Short Life Working Group on Reducing Medication-related Harm.
Citation Text:
The Report of the Short Life Working Group on Reducing Medication-related Harm. Department of Health and Social Care. London, England: Crown Publishing; February 2018.
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psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour
October 04, 2017 - Book/Report
Openness and Honesty When Things Go Wrong: the Professional Duty of Candour.
Citation Text:
Openness and Honesty When Things Go Wrong: the Professional Duty of Candour. London, UK: General Medical Council and the Nursing and Midwifery Council; June 29, 2015.
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psnet.ahrq.gov/issue/criminalization-mistakes-nursing
June 13, 2011 - Commentary
The criminalization of mistakes in nursing.
Citation Text:
Philipsen NC. The Criminalization of Mistakes in Nursing. J Nurs Pract. 2011;7(9):719-726. doi:10.1016/j.nurpra.2011.07.004.
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psnet.ahrq.gov/issue/what-doctors-can-learn-factory-floor
June 13, 2011 - Commentary
What doctors can learn from the factory floor.
Citation Text:
Martyn C. What doctors can learn from the factory floor. BMJ. 2010;340(mar03 3). doi:10.1136/bmj.c1217.
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psnet.ahrq.gov/issue/unlabeled-containers-lead-patients-death
September 26, 2017 - Commentary
Unlabeled containers lead to patient's death.
Citation Text:
Cohen MR, Smetzer JL. Unlabeled containers lead to patient's death. Jt Comm J Qual Patient Saf. 2005;31(7):414-7.
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psnet.ahrq.gov/issue/medical-mistakes-are-more-likely-women-and-minorities
November 01, 2017 - Newspaper/Magazine Article
Medical mistakes are more likely in women and minorities.
Citation Text:
Medical mistakes are more likely in women and minorities. Szabo L. NBC News. January 15, 2024.
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psnet.ahrq.gov/issue/please-dont-sleep-through-wake-call
May 07, 2018 - Newspaper/Magazine Article
Please don't sleep through this wake-up call.
Citation Text:
Please don't sleep through this wake-up call. ISMP Medication Safety Alert! Acute Care Edition. May 2, 2001.
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psnet.ahrq.gov/issue/doctors-fear-criminalization-medical-mistakes
March 28, 2012 - Newspaper/Magazine Article
Doctors fear criminalization of medical mistakes.
Citation Text:
Doctors fear criminalization of medical mistakes. Sorrel AL. American Medical News. November 27, 2006.
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psnet.ahrq.gov/issue/battling-obstetric-malpractice-crisis-improving-patient-safety-part-1
July 05, 2013 - Commentary
Battling the obstetric malpractice crisis: improving patient safety, part 1.
Citation Text:
Battling the obstetric malpractice crisis: improving patient safety, part 1. Bernstein PS. Medscape Ob/Gyn. October 31, 2005.
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psnet.ahrq.gov/issue/2011-annual-benchmarking-report-malpractice-risks-emergency-medicine
July 18, 2018 - Book/Report
2011 Annual Benchmarking Report: Malpractice Risks in Emergency Medicine.
Citation Text:
2011 Annual Benchmarking Report: Malpractice Risks in Emergency Medicine. Ruoff G, ed. Cambridge, MA: CRICO Strategies; 2012.
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psnet.ahrq.gov/issue/field-guide-human-error-investigations-third-edition
April 13, 2018 - Book/Report
Classic
The Field Guide to Human Error Investigations, Third Edition.
Citation Text:
The Field Guide to Human Error Investigations, Third Edition. Dekker S. Boca Baton, FL: CRC Press; 2017.
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psnet.ahrq.gov/issue/er-doctors-misdiagnose-patients-unusual-symptoms
August 05, 2008 - Newspaper/Magazine Article
ER doctors misdiagnose patients with unusual symptoms.
Citation Text:
ER doctors misdiagnose patients with unusual symptoms. Abelson R. New York Times. December 15, 2022.
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psnet.ahrq.gov/node/49412/psn-pdf
September 01, 2003 - Shake Well
September 1, 2003
Flynn EA. Shake Well. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/shake-well
The Case
A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily
serum drug levels consistently fell below the therapeutic range, which led the physi…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
November 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case November 2008
Dangerous Shift
Source and Credits
This presentation is based on the November 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Emily S. Patterson, PhD
Institute for Ergonomics, Ohi…
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psnet.ahrq.gov/node/49511/psn-pdf
May 01, 2006 - Citrate Mix-Up
May 1, 2006
Weber RJ. Citrate Mix-Up. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/citrate-mix
The Case
A 36-year-old woman with multiple sclerosis, diabetes, and chronic renal failure was transferred from a
skilled nursing facility (SNF) to the hospital for treatment of an infection. On a…
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psnet.ahrq.gov/issue/development-national-reporting-and-learning-system-england-and-wales-2001-2005
September 14, 2022 - Commentary
The development of the National Reporting and Learning System in England and Wales, 2001-2005.
Citation Text:
Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and Wales, 2001–2005. Med J Aust. 2019;184(S10) (S10):s65-s68. doi:1…
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psnet.ahrq.gov/issue/death-inside-lemuel-shattuck-hospital-case-study-medical-treatment-persons-mental-health
May 03, 2023 - Book/Report
Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.
Citation Text:
Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities. Massachusetts Protection …
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psnet.ahrq.gov/issue/adverse-incidents-patient-flow-and-nursing-workforce-variables-acute-psychiatric-wards
April 03, 2019 - Study
Adverse incidents, patient flow and nursing workforce variables on acute psychiatric wards: the Tompkins Acute Ward Study.
Citation Text:
Bowers L, Allan T, Simpson A, et al. Adverse incidents, patient flow and nursing workforce variables on acute psychiatric wards: the Tompkins …
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psnet.ahrq.gov/issue/development-and-expression-high-reliability-organization
November 03, 2021 - Commentary
Development and expression of a high-reliability organization.
Citation Text:
Phillips RA, Schwartz RL, Sostman HD, et al. Development and expression of a high-reliability organization. NEJM Catal Innov Care Deliv. 2021;2(12). doi:10.1056/cat.21.0314.
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psnet.ahrq.gov/issue/time-out-analysis
October 19, 2022 - Commentary
Time out: an analysis.
Citation Text:
Dillon KA. Time out: an analysis. AORN J. 2008;88(3):437-442. doi:10.1016/j.aorn.2008.03.003.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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