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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - and trained users of the 3 pumps had a total of 10, 18, and
42 critical, yet unnoticed, errors in 40-minute
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.128_slideshow.ppt
July 01, 2006 - supply for the patient’s needs (flow rate over time of transport to and from destination), plus a 30-minute
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psnet.ahrq.gov/node/49535/psn-pdf
May 01, 2007 - The Commentary
This case—in which an OR anesthesiologist is pressured to step in at the last minute
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psnet.ahrq.gov/node/45978/psn-pdf
May 03, 2017 - Nursing interruptions in a trauma intensive care unit: a
prospective observational study.
May 3, 2017
Craker NC, Myers RA, Eid J, et al. Nursing Interruptions in a Trauma Intensive Care Unit: A Prospective
Observational Study. J Nurs Adm. 2017;47(4):205-211. doi:10.1097/NNA.0000000000000466.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45636/psn-pdf
September 26, 2018 - Pharmacist outpatient prescription review in the
emergency department: a pediatric tertiary hospital
experience.
September 26, 2018
Shah D, Manzi S. Pharmacist Outpatient Prescription Review in the Emergency Department: A Pediatric
Tertiary Hospital Experience. Pediatr Emerg Care. 2018;34(7):497-500.
doi:10.1097/…
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psnet.ahrq.gov/node/837913/psn-pdf
August 31, 2022 - The following morning, her breathing was labored and rapid at 50-60 breaths a minute. … After 7 hours in the community hospital, the patient was tachypneic at 60-80 breaths per minute, hypoxic
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psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - Four
hours later, the patient suddenly became bradycardic to a heart rate of 20 beats per minute.
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psnet.ahrq.gov/sites/default/files/2024-11/spotlight_case_neurological_red_flags_final.pptx
January 01, 2024 - Number of episodes is highly variable, but duration is usually very brief (< 1 minute).
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psnet.ahrq.gov/node/50843/psn-pdf
January 29, 2020 - cases with severe neurologic symptoms, such as seizures or coma, the
panel recommended use of a 10-minute
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psnet.ahrq.gov/node/838190/psn-pdf
September 28, 2015 - Use of an expedited review tool to screen for prior
diagnostic error in emergency department patients.
September 28, 2015
Hudspeth J, El-Kareh R, Schiff G. Use of an expedited review tool to screen for prior diagnostic error in
emergency department patients. Appl Clin Inform. 2015;06(04):619-628. doi:10.4338/aci-20…
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psnet.ahrq.gov/node/43627/psn-pdf
November 12, 2014 - The 5th National Audit Project (NAP5) on accidental
awareness during general anaesthesia: patient
experiences, human factors, sedation, consent and
medicolegal issues.
November 12, 2014
Cook TM, Andrade J, Bogod DG, et al. The 5th National Audit Project (NAP5) on accidental awareness
during general anaesthesia: p…
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psnet.ahrq.gov/node/37346/psn-pdf
March 28, 2012 - Medication administration discrepancies persist despite
electronic ordering.
March 28, 2012
FitzHenry F, Peterson JF, Arrieta M, et al. Medication Administration Discrepancies Persist Despite
Electronic Ordering. J Am Med Inform Assoc. 2007;14(6):756-764. doi:10.1197/jamia.m2359.
https://psnet.ahrq.gov/issue/medic…
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psnet.ahrq.gov/node/35907/psn-pdf
October 03, 2017 - Transparent and open discussion of errors does not
increase malpractice risk in trauma patients.
October 3, 2017
Stewart RM, Corneille MG, Johnston J, et al. Transparent and open discussion of errors does not increase
malpractice risk in trauma patients. Ann Surg. 2006;243(5):645-9; discussion 649-51.
https://psne…
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psnet.ahrq.gov/node/41626/psn-pdf
August 29, 2012 - Impact of resident participation in surgical operations on
postoperative outcomes: National Surgical Quality
Improvement Program.
August 29, 2012
Kiran RP, Ahmed Ali U, Coffey JC, et al. Impact of Resident Participation in Surgical Operations on
Postoperative Outcomes. Ann Surg. 2012;256(3):469-475. doi:10.1097/sl…
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psnet.ahrq.gov/node/36409/psn-pdf
September 28, 2016 - The multitasking clinician: decision-making and cognitive
demand during and after team handoffs in emergency
care.
September 28, 2016
Laxmisan A, Hakimzada F, Sayan OR, et al. The multitasking clinician: decision-making and cognitive
demand during and after team handoffs in emergency care. IntJ Med Inform. 2007;76…
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psnet.ahrq.gov/node/33765/psn-pdf
April 01, 2014 - Because we are dependent on CMS data, we are
also dependent on the fact that CMS data is not up to the minute … were looking at
objects left in after surgery, and my mother just stared at me and she said, "Wait a minute
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psnet.ahrq.gov/web-mm/wrong-channel
February 01, 2003 - and trained users of the 3 pumps had a total of 10, 18, and 42 critical, yet unnoticed, errors in 40-minute
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psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization
Citation Text:
Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Ci…
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psnet.ahrq.gov/node/36150/psn-pdf
September 29, 2010 - Nurse-physician communication during labor and birth:
implications for patient safety.
September 29, 2010
Simpson KR, James DC, Knox E. Nurse-physician communication during labor and birth: implications for
patient safety. J Obstet Gynecol Neonatal Nurs. 2006;35(4):547-56.
https://psnet.ahrq.gov/issue/nurse-physic…
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psnet.ahrq.gov/node/45957/psn-pdf
August 15, 2018 - Comparison of appendectomy outcomes between senior
general surgeons and general surgery residents.
August 15, 2018
Siam B, Al-Kurd A, Simanovsky N, et al. Comparison of Appendectomy Outcomes Between Senior General
Surgeons and General Surgery Residents. JAMA Surg. 2017;152(7):679-685.
doi:10.1001/jamasurg.2017.057…