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psnet.ahrq.gov/issue/5th-national-audit-project-nap5-accidental-awareness-during-general-anaesthesia-patient
October 01, 2014 - Study
The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues.
Citation Text:
Cook TM, Andrade J, Bogod DG, et al. The 5th National Audit Project (NAP5) on accidental awareness …
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psnet.ahrq.gov/issue/simulation-based-evaluation-methods-estimate-impact-adverse-event-hospital-length-stay
December 23, 2011 - Study
A simulation-based evaluation of methods to estimate the impact of an adverse event on hospital length of stay.
Citation Text:
Samore MH, Shen S, Greene T, et al. A simulation-based evaluation of methods to estimate the impact of an adverse event on hospital length of stay. Med C…
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psnet.ahrq.gov/issue/transparent-and-open-discussion-errors-does-not-increase-malpractice-risk-trauma-patients
October 19, 2022 - Study
Transparent and open discussion of errors does not increase malpractice risk in trauma patients.
Citation Text:
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;…
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psnet.ahrq.gov/issue/comparison-appendectomy-outcomes-between-senior-general-surgeons-and-general-surgery
May 03, 2023 - Study
Comparison of appendectomy outcomes between senior general surgeons and general surgery residents.
Citation Text:
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):679-68…
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psnet.ahrq.gov/innovation/catching-those-who-fall-through-cracks-integrating-follow-process-emergency-department
September 09, 2020 - EMERGING INNOVATIONS
Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.
Citation Text:
Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with …
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psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
December 07, 2020 - The Associate Dean of Clinical Affairs, who oversaw the clinical enterprise, sent out a “Monday Minute … They were designed to be read in under a minute and had key educational messaging focused on the epidemiology
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psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry
December 07, 2020 - The Associate Dean of Clinical Affairs, who oversaw the clinical enterprise, sent out a “Monday Minute … They were designed to be read in under a minute and had key educational messaging focused on the epidemiology
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psnet.ahrq.gov/issue/multitasking-clinician-decision-making-and-cognitive-demand-during-and-after-team-handoffs
September 15, 2011 - Study
The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care.
Citation Text:
Laxmisan A, Hakimzada F, Sayan OR, et al. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency c…
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - SPOTLIGHT CASE
A Stroke of Error
Citation Text:
Barrett KM. A Stroke of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/issue/identifying-and-quantifying-medication-errors-evaluation-rapidly-discontinued-medication
February 03, 2011 - Study
Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system.
Citation Text:
Koppel R, Leonard CE, Localio R, et al. Identifying and quantifying medication errors: evaluation of rapidl…
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psnet.ahrq.gov/node/848125/psn-pdf
April 26, 2023 - Every minute counts when responding to an event such as a cardiac arrest, so anything that reduces the
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psnet.ahrq.gov/web-mm/say-it-again
January 31, 2020 - Whoever assumes care of the patient—even during a 10-minute break—needs to have a clear understanding
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psnet.ahrq.gov/web-mm/premature-or-overdue
December 23, 2020 - Fetal heart tones were about 130 per minute. Routine prenatal care was planned.
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - Within a minute, he developed severe abdominal pain and bone pain.
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psnet.ahrq.gov/web-mm/specimen-almost-lost
September 21, 2022 - specimen transport Lack of specimen tracking or chain of custody within laboratory Specimen scant or minute
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psnet.ahrq.gov/node/50696/psn-pdf
November 27, 2019 - Case 1
In the first case, both diphenhydramine and lorazepam were given within a three-minute time period
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psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
July 06, 2022 - April 7, 2022
Reliability and usability of a 7-minute chart review tool to identify
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - SPOTLIGHT CASE
Dangerous Shift
Citation Text:
Patterson ES. Dangerous Shift. 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/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest
Citation Text:
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…
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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - SPOTLIGHT CASE
Unexplained Apnea Under Anesthesia
Citation Text:
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Google Scholar BibTeX …