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psnet.ahrq.gov/issue/patient-safety-factors-children-dying-paediatric-intensive-care-unit-picu-case-notes-review
December 03, 2014 - Study
Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study.
Citation Text:
Monroe K, Wang D, Vincent CA, et al. Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study. BMJ …
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psnet.ahrq.gov/issue/critical-care-safety-study-incidence-and-nature-adverse-events-and-serious-medical-errors
July 15, 2020 - Study
The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care.
Citation Text:
Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical e…
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - Communication Failure—Who's in Charge?
Citation Text:
Fackler J, Schwartz JM. Communication Failure—Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - quickly adopted because it offered a continuous measure of FHR activity and was expected to reduce infant … mortality.( 1-4 ) Both FHR activity and maternal contractions are recorded by transducers placed on
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psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
February 26, 2025 - likelihood of a pregnant patient experiencing a high-risk pregnancy, including outcomes such as maternal and infant … mortality, preterm birth, low birth weight, and increased substance use during pregnancy. 1
IPV is
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psnet.ahrq.gov/issue/reader-bias-breast-cancer-screening-related-cancer-prevalence-and-artificial-intelligence
February 01, 2013 - Study
Reader bias in breast cancer screening related to cancer prevalence and artificial intelligence decision support-a reader study.
Citation Text:
Al-Bazzaz H, Janicijevic M, Strand F. Reader bias in breast cancer screening related to cancer prevalence and artificial intelligence deci…
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psnet.ahrq.gov/issue/hospital-rating-organizations-quality-and-patient-safety-scores-analysis-result-discrepancies
February 22, 2017 - Study
Hospital rating organizations' quality and patient safety scores: analysis of result discrepancies.
Citation Text:
Badr S, Nahle T, Rahman S, et al. Hospital rating organizations' quality and patient safety scores: analysis of result discrepancies. J Gen Intern Med. 2025;40(3):525-…
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psnet.ahrq.gov/issue/adverse-events-neonatal-intensive-care-unit-development-testing-and-findings-nicu-focused
April 11, 2011 - Study
Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs.
Citation Text:
Sharek PJ, Horbar JD, Mason W, et al. Adverse events in the neonatal intensive care unit: development, t…
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psnet.ahrq.gov/issue/effect-reducing-interns-work-hours-serious-medical-errors-intensive-care-units
June 29, 2009 - Study
Classic
Effect of reducing interns' work hours on serious medical errors in intensive care units.
Citation Text:
Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N En…
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - SPOTLIGHT CASE
CME/MOC
Do Not Miss Sepsis Needles in Viral Haystacks!
Citation Text:
Hamline M, Shaikh U. Do Not Miss Sepsis Needles in Viral Haystacks!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Clark Foundation, which has reduced disparities in maternal and infant mortality in Washington, DC.
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - SPOTLIGHT CASE
Dangerous Shift
Citation Text:
Patterson ES. Dangerous Shift. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - Dangerous Shift
November 1, 2008
Patterson ES. Dangerous Shift. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/dangerous-shift
Case Objectives
Review the evidence base on erroneous actions related to shift changes.
Understand the limits of standardizing handoffs in preventing errors at shift change.
Expla…
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psnet.ahrq.gov/innovation/standardized-marking-procedure-ent-operations-prevent-wrong-site-surgery-development
February 01, 2013 - EMERGING INNOVATIONS
A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel.
Citation Text:
Rohrmeier C, Abudan Al-Masry N, Keerl R, et al. A standardized marking procedure for ENT…
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psnet.ahrq.gov/periodic-issue/periodic-issue-389
April 26, 2023 - May 3, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, an…
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psnet.ahrq.gov/periodic-issue/periodic-issue-305
August 25, 2021 - August 18, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports…
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psnet.ahrq.gov/periodic-issue/periodic-issue-376
February 01, 2023 - February 1, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/perspective/equity-patient-safety
September 24, 2024 - Annual Perspective
Equity in Patient Safety
Angela D. Thomas, DrPH, MPH, MBA; Merton Lee, PhD, PharmD; Sarah Mossburg, RN, PhD
| March 27, 2024
View more articles from the same authors.
Citation Text:
Thomas A, Lee M, Mossburg S. Equity in Patient Safety. …
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - SPOTLIGHT CASE
A Weighty Mistake
Citation Text:
Bokser SJ. A Weighty Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…