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psnet.ahrq.gov/issue/when-i-saydiagnostic-error
January 26, 2022 - Commentary
When I say…diagnostic error.
Citation Text:
Hautz WE. When I say… diagnostic error. Med Educ. 2018. doi:10.1111/medu.13602.
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psnet.ahrq.gov/issue/patient-safety-and-acute-care-medicine-lessons-future-insights-past
April 27, 2022 - Review
Patient safety and acute care medicine: lessons for the future, insights from the past.
Citation Text:
Brindley PG. Patient safety and acute care medicine: lessons for the future, insights from the past. Crit Care. 2010;14(2):217. doi:10.1186/cc8858.
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psnet.ahrq.gov/issue/safer-healthcare-strategies-real-world
March 23, 2022 - Book/Report
Classic
Safer Healthcare: Strategies for the Real World.
Citation Text:
Safer Healthcare: Strategies for the Real World. Vincent C, Amalberti R. New York, NY: SpringerOpen; 2016
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psnet.ahrq.gov/issue/demanding-medical-excellence-doctors-and-accountability-information-age
May 13, 2020 - Book/Report
Classic
Demanding Medical Excellence. Doctors and Accountability in the Information Age.
Citation Text:
Demanding Medical Excellence. Doctors and Accountability in the Information Age. Millenson ML. Chicago, IL: University of Chicago Press; 1999. ISB…
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psnet.ahrq.gov/issue/vanishing-nonforensic-autopsy
February 09, 2011 - Commentary
The vanishing nonforensic autopsy.
Citation Text:
Shojania KG, Burton EC. The vanishing nonforensic autopsy. N Engl J Med. 2008;358(9):873-5. doi:10.1056/NEJMp0707996.
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psnet.ahrq.gov/issue/piece-my-mind-im-sorry
November 22, 2017 - Commentary
A piece of my mind. I'm sorry.
Citation Text:
Kahn JS. A PIECE OF MY MIND. I'm Sorry. JAMA. 2015;313(24):2427-8. doi:10.1001/jama.2014.6507.
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psnet.ahrq.gov/issue/improve-health-care-focus-fixing-systems-not-people
September 08, 2021 - Newspaper/Magazine Article
To improve health care, focus on fixing systems — not people.
Citation Text:
Mate KS, Clark J, Salvon-Harman J. To improve health care, focus on fixing systems — not people. Harvard Business Review. July 12, 2024;
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psnet.ahrq.gov/issue/improving-diagnosis-improving-education-policy-brief-education-healthcare-professions
August 28, 2019 - Commentary
Improving diagnosis by improving education: a policy brief on education in healthcare professions.
Citation Text:
Graber ML, Rencic J, Rusz D, et al. Improving diagnosis by improving education: a policy brief on education in healthcare professions. Diagnosis (Berl). 2018;5(3):…
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psnet.ahrq.gov/node/34760/psn-pdf
March 28, 2005 - Managing the Risks of Organizational Accidents.
March 28, 2005
Reason JT. Aldershot, Hants, England: Ashgate: 1997. ISBN: 9781840141047
https://psnet.ahrq.gov/issue/managing-risks-organizational-accidents
Written 7 years after the publication of Human Error, this book demonstrates Reason's thinking at its finest
a…
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psnet.ahrq.gov/issue/ashrm-patient-safety-portal
September 27, 2016 - Multi-use Website
ASHRM Patient Safety Portal.
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March 21, 2012
This Web site provides access to educational resources for risk ma…
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psnet.ahrq.gov/node/47278/psn-pdf
August 15, 2018 - Drawing boundaries: the difficulty in defining clinical
reasoning.
August 15, 2018
Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning.
Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0000000000002142.
https://psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defi…
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psnet.ahrq.gov/node/45815/psn-pdf
January 25, 2017 - Handoffs: transitions of care for children in the
emergency department.
January 25, 2017
American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of
Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association
Pediatric Committee. Pediatrics. 2016;138:…
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psnet.ahrq.gov/node/864375/psn-pdf
March 13, 2024 - Experiences of physicians investigated for
professionalism concerns: a narrative review.
March 13, 2024
Im DS, Tamarelli CM, Shen MR. Experiences of physicians investigated for professionalism concerns: a
narrative review. J Gen Intern Med. 2024;39(2):283-300. doi:10.1007/s11606-023-08550-4.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/35365/psn-pdf
February 17, 2011 - Accidental deaths, saved lives, and improved quality.
February 17, 2011
Brennan TA, Gawande AA, Thomas EJ, et al. Accidental Deaths, Saved Lives, and Improved Quality. New
England Journal of Medicine. 2005;353(13). doi:10.1056/nejmsb051157.
https://psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-qua…
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psnet.ahrq.gov/node/847049/psn-pdf
April 05, 2023 - Effects of racial bias in pulse oximetry on children and
how to address algorithmic bias in clinical medicine.
April 5, 2023
Gray KD, Subramaniam HL, Huang ES. Effects of racial bias in pulse oximetry on children and how to
address algorithmic bias in clinical medicine. JAMA Pediatr. 2023;177(5):459-460.
doi:10.10…
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - U.S. Department of Veterans Affairs Medical Center,
Houston, TX, and Baylor College of Medicine Revised
Safer Diagnosis (Safer Dx) Instrument
January 26, 2022
https://psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-
college-medicine
Summary
The Revised Safer Dx Instr…
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Browse Author Resources
Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - SPOTLIGHT CASE
Prolonged DKA in Pregnancy: A Case of Communication Breakdown.
Citation Text:
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - SPOTLIGHT CASE
How Do Providers Recover From Errors?
Citation Text:
West CP. How Do Providers Recover From Errors?. 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/33769/psn-pdf
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things
Changed?
June 1, 2014
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
Perspective
In 1981, a cancer patient named Paula Carroll founded…