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psnet.ahrq.gov/issue/safe-tables-collaborative-statewide-experience
April 12, 2011 - Commentary
The Safe Tables Collaborative: a statewide experience.
Citation Text:
Wagner CA, Cecchettini D, Fletcher J. The safe tables collaborative: a statewide experience. Jt Comm J Qual Patient Saf. 2011;37(5):206-10, 193.
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psnet.ahrq.gov/issue/assessing-hospital-safety-nights-and-weekends-swan-tool
September 28, 2010 - Commentary
Assessing hospital safety on nights and weekends: the SWAN tool.
Citation Text:
Shulkin DJ. Assessing hospital safety on nights and weekends: the SWAN tool. J Patient Saf. 2009;5(2):75-8. doi:10.1097/PTS.0b013e3181a5db10.
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DOI Google Schola…
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psnet.ahrq.gov/issue/future-emergency-care-united-states-health-system
June 16, 2012 - Book/Report
The Future of Emergency Care in the United States Health System.
Citation Text:
The Future of Emergency Care in the United States Health System. Institute of Medicine. Washington DC; National Academies Press: 2007.
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psnet.ahrq.gov/issue/view-world-through-different-lens-shadowing-another-provider
January 22, 2017 - Commentary
View the world through a different lens: shadowing another provider.
Citation Text:
Thompson DA, Holzmueller CG, Lubomski LH, et al. View the world through a different lens: shadowing another provider. Jt Comm J Qual Patient Saf. 2008;34(10):614-8, 561.
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psnet.ahrq.gov/issue/health-it-and-patient-safety-building-safer-systems-better-care
June 16, 2011 - Book/Report
Classic
Health IT and Patient Safety: Building Safer Systems for Better Care.
Citation Text:
Health IT and Patient Safety: Building Safer Systems for Better Care. Committee on Patient Safety and Health Information Technology, Board on Health Care Ser…
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psnet.ahrq.gov/issue/ambulatory-medication-errors-and-adverse-events-involved-medicine-related-malpractice-cases
November 18, 2016 - Study
Ambulatory medication errors and adverse events involved in medicine-related malpractice cases from 2011 to 2021.
Citation Text:
Boisvert S, Nelson M, Ross J. Ambulatory medication errors and adverse events involved in medicine-related malpractice cases from 2011 to 2021. J Patient…
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psnet.ahrq.gov/issue/best-care-lower-cost-path-continuously-learning-health-care-america
July 08, 2016 - Book/Report
Classic
Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.
Citation Text:
Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Committe…
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psnet.ahrq.gov/issue/role-patient-involvement-diagnostic-process-internal-medicine-cognitive-approach
April 25, 2012 - Commentary
The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach.
Citation Text:
Lucchiari C, Pravettoni G. The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach. Eur J Intern Med. 2013;24(5):4…
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psnet.ahrq.gov/issue/pediatric-patient-safety-prehospitalemergency-department-setting
June 21, 2010 - Review
Pediatric patient safety in the prehospital/emergency department setting.
Citation Text:
Barata IA, Benjamin LS, Mace SE, et al. Pediatric patient safety in the prehospital/emergency department setting. Pediatr Emerg Care. 2007;23(6):412-8.
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psnet.ahrq.gov/issue/risk-factors-missed-colorectal-lesions-after-colonoscopy
March 25, 2020 - Study
Risk factors of missed colorectal lesions after colonoscopy.
Citation Text:
Lee J, Park SW, Kim YS, et al. Risk factors of missed colorectal lesions after colonoscopy. Medicine (Baltimore). 2017;96(27):e7468. doi:10.1097/MD.0000000000007468.
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DOI …
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psnet.ahrq.gov/issue/what-if-transforming-diagnostic-research-leveraging-diagnostic-process-map-engage-patients
October 27, 2021 - Book/Report
What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors.
Citation Text:
Sheridan S, Merryweather P, Rusz D, et al. What If?: Transforming Diagnostic Research By Leveraging A Diagnostic Process Map To Engage …
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psnet.ahrq.gov/issue/method-identify-pediatric-high-risk-diagnoses-missed-emergency-department
October 26, 2022 - Study
A method to identify pediatric high-risk diagnoses missed in the emergency department.
Citation Text:
Sundberg M, Perron CO, Kimia A, et al. A method to identify pediatric high-risk diagnoses missed in the emergency department. Diagnosis (Berl). 2018;5(2):63-69. doi:10.1515/dx-2018…
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psnet.ahrq.gov/issue/depth-investigation-causes-prescribing-errors-foundation-trainees-relation-their-medical
May 16, 2012 - Book/Report
An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.
Citation Text:
An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUI…
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psnet.ahrq.gov/issue/practice-advisory-intraoperative-awareness-and-brain-function-monitoring
July 16, 2018 - Review
Practice Advisory on Intraoperative Awareness and Brain Function Monitoring.
Citation Text:
Awareness AS of ATF on I. Practice advisory for intraoperative awareness and brain function monitoring: a report by the american society of anesthesiologists task force on intraoperative …
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psnet.ahrq.gov/issue/culture-safety-ems-systems-0
February 18, 2011 - Organizational Policy/Guidelines
A culture of safety in EMS systems.
Citation Text:
A culture of safety in EMS systems. American College of Emergency Physicians, National Association of Emergency Medical Services. Ann Emerg Med. 2021;78(3):e37-e57.
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psnet.ahrq.gov/issue/effect-acgme-duty-hours-attending-physician-teaching-and-satisfaction
February 17, 2009 - Study
Effect of ACGME duty hours on attending physician teaching and satisfaction.
Citation Text:
Arora V, Meltzer DO. Effect of ACGME duty hours on attending physician teaching and satisfaction. Arch Intern Med. 2008;168(11):1226-8. doi:10.1001/archinte.168.11.1226.
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psnet.ahrq.gov/node/47354/psn-pdf
November 21, 2018 - Improving Diagnosis in Medicine Change Package.
November 21, 2018
Chicago, IL: Health Research & Educational Trust; 2018.
https://psnet.ahrq.gov/issue/improving-diagnosis-medicine-change-package
Proactive identification of conditions that degrade the diagnostic process can drive improvement. This
toolkit provides …
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psnet.ahrq.gov/node/74142/psn-pdf
January 02, 2024 - Robert L. Wears Patient Safety Leadership Award.
November 1, 2023
Regional Center at Jacksonville University, University of Florida College of Medicine – Jacksonville, FL.
https://psnet.ahrq.gov/issue/robert-l-wears-patient-safety-leadership-award
Inspired by the research and leadership of Dr. Robert Wears, this aw…
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psnet.ahrq.gov/node/34751/psn-pdf
March 07, 2005 - Merry and McCall Smith's Errors, Medicine, and the Law.
2nd ed.
March 7, 2005
Merry A, Brookbanks W. Cambridge, UK: Cambridge University Press; 2017. ISBN: 9781107180499
https://psnet.ahrq.gov/issue/errors-medicine-and-law
Merry, a New Zealand anesthesiologist, and Smith, a legal educator and a popular writer, exp…
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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…