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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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psnet.ahrq.gov/web-mm/unfamiliar-catheter
November 01, 2006 - The Unfamiliar Catheter
Citation Text:
Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/node/39663/psn-pdf
June 09, 2011 - Value of human factors to medication and patient safety
in the intensive care unit.
June 9, 2011
Scanlon M, Karsh B-T. Value of human factors to medication and patient safety in the intensive care unit.
Crit Care Med. 2010;38. doi:10.1097/ccm.0b013e3181dd8de2.
https://psnet.ahrq.gov/issue/value-human-factors-medic…
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psnet.ahrq.gov/node/36264/psn-pdf
October 21, 2010 - The importance of establishing regimen concordance in
preventing medication errors in anticoagulant care.
October 21, 2010
Schillinger D, Wang F, Rodriguez M, et al. The importance of establishing regimen concordance in
preventing medication errors in anticoagulant care. J Health Commun. 2006;11(6):555-67.
https:/…
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psnet.ahrq.gov/node/43293/psn-pdf
June 25, 2014 - Health-care providers want patients to read medical
records, spot errors.
June 25, 2014
Landro L. Wall Street Journal. June 9, 2014.
https://psnet.ahrq.gov/issue/health-care-providers-want-patients-read-medical-records-spot-errors
As they become more prevalent, electronic medical records (EMRs) are being used to i…
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psnet.ahrq.gov/node/41707/psn-pdf
November 26, 2014 - Electronic medical record availability and primary care
depression treatment.
November 26, 2014
Harman JS, Rost KM, Harle CA, et al. Electronic medical record availability and primary care depression
treatment. J Gen Intern Med. 2012;27(8):962-7. doi:10.1007/s11606-012-2001-0.
https://psnet.ahrq.gov/issue/electron…
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psnet.ahrq.gov/node/39472/psn-pdf
April 21, 2010 - Characteristics of medical professional liability claims in
patients with cardiovascular diseases.
April 21, 2010
Oetgen WJ, Parikh D, Cacchione JG, et al. Characteristics of medical professional liability claims in
patients with cardiovascular diseases. Am J Cardiol. 2010;105(5):745-52.
doi:10.1016/j.amjcard.2009…
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psnet.ahrq.gov/node/61052/psn-pdf
April 01, 2019 - Inadvertent Administration of an Oral Liquid Medicine into
a Vein.
April 1, 2019
Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.
https://psnet.ahrq.gov/issue/inadvertent-administration-oral-liquid-medicine-vein
Wrong route medication administration is a never event. This report examined the co…
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psnet.ahrq.gov/node/42025/psn-pdf
February 06, 2013 - Medical malpractice: why is it so hard for doctors to
apologize?
February 6, 2013
Sanghavi D.
https://psnet.ahrq.gov/issue/medical-malpractice-why-it-so-hard-doctors-apologize
Discussing barriers to physician error disclosure, this article details how an apology-and-offer approach and
analyzing claims data can im…
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psnet.ahrq.gov/node/41668/psn-pdf
December 21, 2014 - A surgical simulation curriculum for senior medical
students based on TeamSTEPPS.
December 21, 2014
Meier AH, Boehler ML, McDowell CM, et al. A surgical simulation curriculum for senior medical students
based on TeamSTEPPS. Arch Surg. 2012;147(8):761-6. doi:10.1001/archsurg.2012.1340.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/41013/psn-pdf
January 01, 2012 - Patient safety in emergency medical services: a
systematic review of the literature.
December 21, 2011
Bigham BL, Buick JE, Brooks SC, et al. Patient safety in emergency medical services: a systematic review
of the literature. Prehosp Emerg Care. 2012;16(1):20-35. doi:10.3109/10903127.2011.621045.
https://psnet.ah…
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psnet.ahrq.gov/node/39899/psn-pdf
October 06, 2010 - Comparison of the clinical diagnosis and subsequent
autopsy findings in medical malpractice.
October 6, 2010
Pakis I, Polat O, Yayci N, et al. Comparison of the clinical diagnosis and subsequent autopsy findings in
medical malpractice. Am J Forensic Med Pathol. 2010;31(3):218-21. doi:10.1097/PAF.0b013e3181e040d4.
…
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psnet.ahrq.gov/node/35725/psn-pdf
July 14, 2010 - Characteristics of medication errors made by students
during the administration phase: a descriptive study.
July 14, 2010
Wolf ZR, Hicks RW, Serembus JF. Characteristics of medication errors made by students during the
administration phase: a descriptive study. J Prof Nurs. 2006;22(1):39-51.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/35110/psn-pdf
April 06, 2011 - Medication safety program reduces adverse drug events
in a community hospital.
April 6, 2011
Cohen MM, Kimmel NL, Benage MK, et al. Medication safety program reduces adverse drug events in a
community hospital. Qual Saf Health Care. 2005;14(3):169-74.
https://psnet.ahrq.gov/issue/medication-safety-program-reduces-…
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psnet.ahrq.gov/node/34741/psn-pdf
December 19, 2018 - Wall of Silence: The Untold Story of the Medical Mistakes
That Kill and Injure Millions of Americans.
December 19, 2018
Gibson R, Singh JP. Washington DC, LifeLine Press; 2003.
https://psnet.ahrq.gov/issue/wall-silence-untold-story-medical-mistakes-kill-and-injure-millions-americans
Written by a program officer at…
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psnet.ahrq.gov/node/37379/psn-pdf
March 28, 2012 - Identifying modifiable barriers to medication error
reporting in the nursing home setting.
March 28, 2012
Handler S, Perera S, Olshansky EF, et al. Identifying modifiable barriers to medication error reporting in the
nursing home setting. J Am Med Dir Assoc. 2007;8(9):568-74.
https://psnet.ahrq.gov/issue/identifyi…
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psnet.ahrq.gov/node/42276/psn-pdf
May 15, 2013 - Kadcyla (ado-trastuzumab emtansine): drug safety
communication—potential medication errors resulting
from name confusion.
May 15, 2013
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; May 6, 2013.
https://psnet.ahrq.gov/issue/kadcyla-ado-trastuzumab-emtansine-drug-safety-communication-pot…
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psnet.ahrq.gov/node/40775/psn-pdf
September 14, 2011 - Ambulatory surgery facilities: a comprehensive review of
medication error reports in Pennsylvania.
September 14, 2011
Grissinger M, Dabliz R. Pa Patient Saf Advis 2011 Sep;8(3):85-93.
https://psnet.ahrq.gov/issue/ambulatory-surgery-facilities-comprehensive-review-medication-error-reports-
pennsylvania
Anal…
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psnet.ahrq.gov/node/37962/psn-pdf
September 12, 2016 - Exploratory analyses of the "failure to rescue" measure:
evaluation through medical record review.
September 12, 2016
Talsma AN, Bahl V, Campbell D. Exploratory analyses of the "failure to rescue" measure: evaluation
through medical record review. J Nurs Care Qual. 2008;23(3):202-210.
doi:10.1097/01.NCQ.0000324583…