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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - January 17, 2018
An objective methodology for task analysis and workload assessment in
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psnet.ahrq.gov/node/867651/psn-pdf
February 26, 2025 - Therefore, Safety II cannot be employed as a methodology
to mitigate error or even reduce harm: it is
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psnet.ahrq.gov/node/37363/psn-pdf
February 03, 2011 - Effect of a rapid response team on hospital-wide mortality
and code rates outside the ICU in a children’s hospital.
February 3, 2011
Sharek PJ, Parast L, Leong K, et al. Effect of a rapid response team on hospital-wide mortality and code
rates outside the ICU in a Children's Hospital. JAMA. 2007;298(19):2267-74.
h…
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psnet.ahrq.gov/node/38120/psn-pdf
June 16, 2011 - Organizational culture, team climate and diabetes care in
small office-based practices.
June 16, 2011
Bosch M, Dijkstra R, Wensing M, et al. Organizational culture, team climate and diabetes care in small
office-based practices. BMC Health Serv Res. 2008;8:180. doi:10.1186/1472-6963-8-180.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/44079/psn-pdf
May 28, 2015 - Differences in the rates of patient safety events by payer:
implications for providers and policymakers.
May 28, 2015
Spencer CS, Roberts ET, Gaskin DJ. Differences in the rates of patient safety events by payer: implications
for providers and policymakers. Med Care. 2015;53(6):524-9. doi:10.1097/MLR.00000000000003…
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psnet.ahrq.gov/node/40893/psn-pdf
November 02, 2011 - Systematic review of safety checklists for use by medical
care teams in acute hospital settings—limited evidence of
effectiveness.
November 2, 2011
Ko HCH, Turner TJ, Finnigan MA. Systematic review of safety checklists for use by medical care teams in
acute hospital settings--limited evidence of effectiveness. BMC…
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psnet.ahrq.gov/node/45116/psn-pdf
February 15, 2017 - Postoperative adverse events inconsistently improved by
the World Health Organization surgical safety checklist: a
systematic literature review of 25 studies.
February 15, 2017
de Jager E, McKenna C, Bartlett L, et al. Postoperative adverse events inconsistently improved by the
World Health Organization surgical s…
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psnet.ahrq.gov/node/39788/psn-pdf
April 21, 2011 - Effects of reducing or eliminating resident work shifts
over 16 hours: a systematic review.
April 21, 2011
Levine AC, Adusumilli J, Landrigan CP. Effects of reducing or eliminating resident work shifts over 16
hours: a systematic review. Sleep. 2010;33(8):1043-53. doi:10.1093/sleep/33.8.1043.
https://psnet.ahrq.go…
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - Therefore, AI systems may unknowingly apply programmed methodology for assessment inappropriately, resulting
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psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
August 01, 2017 - As people accept the idea of measurement, do they buy that the methodology is good enough—both in the
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - The training focuses on methodology and technical skills that are broadly applicable but, frankly, technical
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psnet.ahrq.gov/node/43687/psn-pdf
November 12, 2014 - Changes in medical errors after implementation of a
handoff program.
November 12, 2014
Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff
program. New Engl J Med. 2014;371(19):1803-1812. doi:10.1056/NEJMsa1405556.
https://psnet.ahrq.gov/issue/changes-medical-er…
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psnet.ahrq.gov/node/45113/psn-pdf
May 11, 2016 - Medical error—the third leading cause of death in the US.
May 11, 2016
Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.
doi:10.1136/bmj.i2139.
https://psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us
How many patients die each year due to preventabl…
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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
September 18, 2024 - SPOTLIGHT CASE
Diagnostic Delay in the Emergency Department
Citation Text:
Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:…
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - Annual Perspective
Ensuring Patient and Workforce Safety Culture in Healthcare
John Murray, Joann Sorra, Bryan Gale, Sarah Mossburg
| March 27, 2024
View more articles from the same authors.
Citation Text:
Murray J, Sorra J, Gale B, et al. Ensuring Patient…
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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psnet.ahrq.gov/node/33728/psn-pdf
May 01, 2012 - In Conversation With…David C. Classen, MD, MS
May 1, 2012
In Conversation With…David C. Classen, MD, MS. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
Editor's note: David C. Classen, MD, MS, is Chief Medical Information Officer for Pascal Metrics and an
Associa…
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psnet.ahrq.gov/node/43042/psn-pdf
December 18, 2014 - Introduction of surgical safety checklists in Ontario,
Canada.
December 18, 2014
Urbach DR, Govindarajan A, Saskin R, et al. Introduction of Surgical Safety Checklists in Ontario, Canada.
New Engl J Med. 2014;370(11):1029-1038. doi:10.1056/nejmsa1308261.
https://psnet.ahrq.gov/issue/introduction-surgical-safety-ch…