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psnet.ahrq.gov/issue/first-year-who-surgical-safety-checklist-7148-otorhinolaryngological-operations-use-and-user
October 30, 2019 - Study
First year with WHO Surgical Safety Checklist in 7148 otorhinolaryngological operations: use and user attitudes.
Citation Text:
Helmiö P, Takala A, Aaltonen L-M, et al. First year with WHO Surgical Safety Checklist in 7148 otorhinolaryngological operations: use and user attitudes…
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psnet.ahrq.gov/issue/geometric-probability-distribution-modeling-error-risk-during-prescription-dispensing
December 24, 2008 - Study
Geometric probability distribution for modeling of error risk during prescription dispensing.
Citation Text:
Carnahan BJ, Maghsoodloo S, Flynn EA, et al. Geometric probability distribution for modeling of error risk during prescription dispensing. Am J Health Syst Pharm. 2006;63(…
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psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-trade-offs
November 04, 2020 - Commentary
Scandal as a sentinel event—recognizing hidden cost–quality trade-offs.
Citation Text:
Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med. 2016;374(11):1001-3. doi:10.1056/NEJMp1502629.
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DOI Google…
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psnet.ahrq.gov/issue/ethical-considerations-disclosure-when-medical-error-discovered-during-medicolegal-death
December 14, 2016 - Commentary
Ethical considerations on disclosure when medical error is discovered during medicolegal death investigation.
Citation Text:
Wolf DA, Drake SA, Snow FK. Ethical Considerations on Disclosure When Medical Error Is Discovered During Medicolegal Death Investigation. Am J Forensic …
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psnet.ahrq.gov/issue/outcomes-card-development-systems-based-practice-educational-tool
July 13, 2010 - Study
The outcomes card: development of a systems-based practice educational tool.
Citation Text:
Tomolo A, Caron A, Perz ML, et al. The outcomes card. J Gen Intern Med. 2005;20(8). doi:10.1111/j.1525-1497.2005.0168.x.
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DOI Google Scholar BibTeX EndNo…
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psnet.ahrq.gov/issue/implementing-nurse-shadowing-program-first-year-medical-students-improve-interprofessional
January 15, 2025 - Commentary
Implementing a nurse-shadowing program for first-year medical students to improve interprofessional collaborations on health care teams.
Citation Text:
Jain A, Luo E, Yang J, et al. Implementing a nurse-shadowing program for first-year medical students to improve interprofessi…
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psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
April 01, 2018 - The rates of infection, bleeding, blood clots, and falls were increasing—in addition to the risk of whatever
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psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
April 01, 2013 - from other industries that once an individual hits 3 or 4 nights in a row, the risk of error begins increasing
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psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - The rates of infection, bleeding, blood clots, and falls were increasing—in addition to the risk of whatever
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psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
May 19, 2021 - or support to intervene on postdischarge issues may actually increase visits to the ED, potentially increasing
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psnet.ahrq.gov/web-mm/dissecting-presentation
May 05, 2021 - We do know that there is a higher incidence of AAD in men (65%) and with increasing age.( 4 ) Clinical
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psnet.ahrq.gov/node/60542/psn-pdf
May 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride
May 27, 2020
Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
The Case
An infant with trisomy 21 underwent repair of a…
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - Falling Through the Crack (in the Bedrails)
May 1, 2016
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
Case Objectives
Review the epidemiology of patient falls and associated injuries in the hospital set…
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong
Medication
September 30, 2020
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
The Case
A 65-year-old woman co…
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psnet.ahrq.gov/web-mm/beeline-spine
March 01, 2014 - SPOTLIGHT CASE
Beeline to Spine
Citation Text:
Smetana GW. Beeline to Spine. 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/72516/psn-pdf
November 25, 2020 - Premature Closure: Was It Just Syncope?
November 25, 2020
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - volumes of patients to cover overhead costs, decreasing the time spent with patients and potentially increasing … In the context of primary care provider shortages, especially in rural and underserved communities, increasing … access can be achieved by increasing and sustaining the primary care workforce, expanding the use of
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psnet.ahrq.gov/issue/corridor-care-emergency-department-managing-patient-care-non-clinical-areas-safely-and
May 19, 2021 - Commentary
'Corridor care' in the emergency department: managing patient care in non-clinical areas safely and efficiently.
Citation Text:
Williams C. ‘Corridor care’ in the emergency department: managing patient care in non-clinical areas safely and efficiently. Emerg Nurse. 2023;31(6):…
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psnet.ahrq.gov/issue/excess-cost-and-length-stay-associated-voluntary-patient-safety-event-reports-hospitals
October 19, 2022 - Study
Excess cost and length of stay associated with voluntary patient safety event reports in hospitals.
Citation Text:
Paradis AR, Stewart VT, Bayley KB, et al. Excess Cost and Length of Stay Associated With Voluntary Patient Safety Event Reports in Hospitals. American Journal of M…
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psnet.ahrq.gov/issue/association-between-surgeon-stress-and-major-surgical-complications
November 29, 2023 - Study
Association between surgeon stress and major surgical complications.
Citation Text:
Awtry J, Skinner S, Polazzi S, et al. Association between surgeon stress and major surgical complications. JAMA Surg. 2025;160(3):332-340. doi:10.1001/jamasurg.2024.6072.
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