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psnet.ahrq.gov/node/33638/psn-pdf
August 01, 2006 - Getting Into Patient Safety: A Personal Story
August 1, 2006
Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
Perspective
My journey into patient safety began in 1972. It was born of serendipity enabled by the…
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psnet.ahrq.gov/node/33846/psn-pdf
November 01, 2017 - The Role of Patient-facing Technologies to Empower
Patients and Improve Safety
November 1, 2017
Rozenblum R, Bates DW. The Role of Patient-facing Technologies to Empower Patients and Improve
Safety. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-imp…
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psnet.ahrq.gov/node/33840/psn-pdf
August 01, 2017 - ACGME's 2017 Revision of Common Program
Requirements
August 1, 2017
Malloy K, Brigham TP, Nasca TJ. ACGME's 2017 Revision of Common Program Requirements. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/acgmes-2017-revision-common-program-requirements
Perspective
The Accreditation Council for Graduate …
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psnet.ahrq.gov/node/49587/psn-pdf
May 01, 2009 - Missing Trauma
May 1, 2009
Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/missing-trauma
The Case
A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a
few minutes later by a customer, who immediately called 911. On arrival, para…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005
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Citation Text:
Conway JB, Weingart SN. Organizational Change…
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psnet.ahrq.gov/node/49805/psn-pdf
September 01, 2017 - The Forgotten Radiographic Read
September 1, 2017
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read
The Case
A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for
management of inferior…
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - Medication Errors and Adverse Drug Events
Citation Text:
Medication Errors and Adverse Drug Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote…
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psnet.ahrq.gov/web-mm/copy-and-paste
December 10, 2014 - Copy and Paste
Citation Text:
Hersh WR. Copy and Paste. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/curated-library/diagnostic-error
August 10, 2025 - The majority of the diagnostic errors resulted in some form of clinical impact, including short-term … Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases … Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - accessible, and equitable healthcare by interprofessional teams who are accountable for addressing the majority … indicated that preventable, manageable health conditions (e.g., diabetes, hypertension) make up the majority … then, when I started working in the mental health safety net clinic system, I realized that the vast majority … I think, you know, the vast majority of medical providers come through trainings that don't really have
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psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance
Lance L. Roberts, MS; Marcia M. Ward, PhD; Thomas C. Evans, MD | April 1, 2010
Also Read a Conversation
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…
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psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
May 01, 2018 - In Conversation with…David W. Bates, MD, MSc
May 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…David W. Bates, MD, MSc. 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/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
May 01, 2008 - Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work?
Josh Peterson, MD, MPH | May 1, 2018
Also Read a Conversation
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Citation Text:
Peterson JF. Integrating Multiple Medication Decision …
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psnet.ahrq.gov/issue/creating-high-reliability-health-care-system-improving-performance-core-processes-care-johns
January 27, 2016 - Study
Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine.
Citation Text:
Pronovost P, Armstrong M, Demski R, et al. Creating a high-reliability health care system: improving performance on core processes of care at Jo…
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psnet.ahrq.gov/issue/tempos-management-primary-care-key-factor-classifying-adverse-events-and-improving-quality
March 15, 2017 - Study
'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety.
Citation Text:
Amalberti R, Brami J. 'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety. BMJ Qual Saf.…
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psnet.ahrq.gov/issue/burden-opioid-related-mortality-united-states
June 02, 2021 - Study
Classic
The burden of opioid-related mortality in the United States.
Citation Text:
Gomes T, Tadrous M, Mamdani MM, et al. The burden of opioid-related mortality in the United States. JAMA Netw Open. 2018;1(2):e180217. doi:10.1001/jamanetworkopen.2018.0217…
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psnet.ahrq.gov/issue/barriers-and-motivators-making-error-reports-family-medicine-offices-report-american-academy
July 14, 2010 - Study
Barriers and motivators for making error reports from family medicine offices: a report from the American Academy of Family Physicians National Research Network (AAFP NRN).
Citation Text:
Elder NC, Graham D, Brandt E, et al. Barriers and motivators for making error reports from f…
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - ineffective strategy for preventing further patient safety mishaps, particularly
considering that the majority … The majority of respondents, in all groups,
endorsed punitive measures such as fines, suspensions, or
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - High-Risk Pregnancy Program links clinicians and
patients across the state with UAMS, where the vast majority … Pregnancy Program links patients and clinicians across the state with the medical center,
where the vast majority … The majority of
referrals continue to be managed locally, but patients with abnormal findings may be … access to consultations: Since the implementation of the High-Risk Pregnancy
Program in 2003, the vast majority … Renewing annually, the program contract dedicates
the majority of funding toward the telemedicine infrastructure
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psnet.ahrq.gov/node/33853/psn-pdf
March 01, 2018 - But it is
disappointing that in the majority of hospitals there has been no change, and some hospitals … A majority of nurses say that they and other staff feel like their mistakes are held against them
and … RW: The majority of nurses in hospitals are working with and through technology.