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psnet.ahrq.gov/issue/infection-control-deficiencies-were-widespread-and-persistent-nursing-homes-prior-covid-19
April 29, 2020 - Book/Report
Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.
Citation Text:
Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic. Washington, DC: United States Government Accoun…
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psnet.ahrq.gov/issue/etiology-diagnostic-errors-controlled-trial-system-1-versus-system-2-reasoning
July 02, 2014 - Study
The etiology of diagnostic errors: a controlled trial of System 1 versus System 2 reasoning.
Citation Text:
Norman GR, Sherbino J, Dore KL, et al. The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. Acad Med. 2014;89(2):277-84. doi:10.1097…
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psnet.ahrq.gov/issue/tale-two-stories-contrasting-views-patient-safety
March 27, 2005 - Book/Report
Classic
A Tale of Two Stories: Contrasting Views of Patient Safety.
Citation Text:
A Tale of Two Stories: Contrasting Views of Patient Safety. Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1997.
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psnet.ahrq.gov/issue/parental-involvement-preoperative-surgical-safety-checklist-welcomed-both-parents-and-staff
April 12, 2011 - Study
Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff.
Citation Text:
Corbally MT, Tierney E. Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff. Int J Pediatr. 2014;2014:791490…
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psnet.ahrq.gov/issue/hospital-image-repair-strategies-organizational-apology-and-medical-errors-analysis-coxhealth
July 17, 2024 - Commentary
Hospital image repair strategies, organizational apology, and medical errors: an analysis of the CoxHealth brain over-radiation case.
Citation Text:
Carmack HJ. Hospital Image Repair Strategies, Organizational Apology, and Medical Errors: An Analysis of the CoxHealth Brain Ove…
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psnet.ahrq.gov/issue/implementation-second-victim-program-pediatric-hospital
December 18, 2013 - Study
Implementation of a "second victim" program in a pediatric hospital.
Citation Text:
Krzan KD, Merandi J, Morvay S, et al. Implementation of a "second victim" program in a pediatric hospital. Am J Health Syst Pharm. 2015;72(7):563-7. doi:10.2146/ajhp140650.
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Forma…
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psnet.ahrq.gov/issue/considering-human-factors-and-developing-systems-thinking-behaviours-ensure-patient-safety
March 01, 2023 - Newspaper/Magazine Article
Considering human factors and developing systems-thinking behaviours to ensure patient safety.
Citation Text:
Considering human factors and developing systems-thinking behaviours to ensure patient safety. Vosper H; Lim R; Knight C; et al; CIEHF Pharmaceutical H…
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psnet.ahrq.gov/node/38894/psn-pdf
August 26, 2009 - Negotiating medical virtues: toward the development of a
physician mistake disclosure model.
August 26, 2009
Hannawa AF. Negotiating medical virtues: toward the development of a physician mistake disclosure
model. Health Comm. 2009;24(5):391-399. doi:10.1080/10410230903023279.
https://psnet.ahrq.gov/issue/negotiat…
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psnet.ahrq.gov/node/39296/psn-pdf
January 22, 2017 - Applying Lean Sigma solutions to mistake-proof the
chemotherapy preparation process.
January 22, 2017
Aboumatar HJ, Winner L, Davis RO, et al. Applying Lean Sigma solutions to mistake-proof the
chemotherapy preparation process. Jt Comm J Qual Patient Saf. 2010;36(2):79-86.
https://psnet.ahrq.gov/issue/applying-lea…
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psnet.ahrq.gov/node/39964/psn-pdf
January 04, 2011 - Fatal consequences of a simple mistake: how can a
patient be saved from inadvertent intrathecal vincristine?
January 4, 2011
Reddy K, Brown B, Nanda A. Fatal consequences of a simple mistake: how can a patient be saved from
inadvertent intrathecal vincristine? Clin Neurol Neurosurg. 2011;113(1):68-71.
doi:10.1016/…
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psnet.ahrq.gov/node/841774/psn-pdf
December 21, 2022 - The prosecution of RaDonda Vaught: an ethical and legal
mistake.
December 21, 2022
Vogelstein E. The prosecution of RaDonda Vaught: An ethical and legal mistake. Nurs Forum.
2022;57(6):1571-1574. doi:10.1111/nuf.12838.
https://psnet.ahrq.gov/issue/prosecution-radonda-vaught-ethical-and-legal-mistake
The criminal …
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psnet.ahrq.gov/node/60717/psn-pdf
July 22, 2020 - The U.S. is repeating its deadliest pandemic mistake.
July 22, 2020
KHAZAN OLGA. The U.S. is repeating its deadliest pandemic mistake. The Atlantic. 2020;July 6.
https://psnet.ahrq.gov/issue/us-repeating-its-deadliest-pandemic-mistake
Residential care facilities have been particularly challenged by COVID-19. This a…
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psnet.ahrq.gov/node/46037/psn-pdf
April 16, 2018 - 'If no-one stops me, I'll make the mistake again': changing
prescribing behaviours through feedback; a Perceptual
Control Theory perspective.
April 16, 2018
Ferguson J, Keyworth C, Tully MP. 'If no-one stops me, I'll make the mistake again': Changing prescribing
behaviours through feedback; A Perceptual Control Th…
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psnet.ahrq.gov/node/39241/psn-pdf
March 05, 2010 - Dealing honestly with an honest mistake.
March 5, 2010
Liang NL, Herring ME, Bush RL. Dealing honestly with an honest mistake. J Vasc Surg. 2010;51(2):494-5.
doi:10.1016/j.jvs.2009.11.001.
https://psnet.ahrq.gov/issue/dealing-honestly-honest-mistake
This case report describes a near miss involving a potential hepa…
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psnet.ahrq.gov/node/39771/psn-pdf
August 18, 2010 - Bearing witness to the ethics of practice: storying
physicians' medical mistake narratives.
August 18, 2010
Carmack HJ. Bearing witness to the ethics of practice: storying physicians' medical mistake narratives.
Health Commun. 2010;25(5):449-58. doi:10.1080/10410236.2010.484876.
https://psnet.ahrq.gov/issue/bearin…
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psnet.ahrq.gov/node/37148/psn-pdf
March 11, 2009 - CMS: your mistake, your problem.
March 11, 2009
Lubell J. CMS: your mistake, your problem. Eight hospital-acquired conditions won't be paid for. Modern
healthcare. 2007;37(33):10-1.
https://psnet.ahrq.gov/issue/cms-your-mistake-your-problem
This article discusses the challenges hospitals face in responding to rece…
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psnet.ahrq.gov/node/37044/psn-pdf
September 05, 2007 - Make no mistake about it: chain pharmacies are finding
innovative ways to combat medication errors.
September 5, 2007
Levy S. Drug Topics. July 9, 2007
https://psnet.ahrq.gov/issue/make-no-mistake-about-it-chain-pharmacies-are-finding-innovative-ways-
combat-medication
This article reports on ways in which chain …
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psnet.ahrq.gov/node/42753/psn-pdf
November 20, 2013 - Dealing with a medical mistake: should physicians
apologize to patients?
November 20, 2013
Tabler NG Jr.
https://psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients
This article discusses how apologies address patients' needs when a medical mistake has occurred and
how such disclosur…
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psnet.ahrq.gov/node/39344/psn-pdf
March 03, 2010 - Mistake-proofing healthcare: why stopping processes
may be a good start.
March 3, 2010
Grout JR, Toussaint JS. Mistake-proofing healthcare: Why stopping processes may be a good start. Bus
Horiz. 2009;53(2):149-156. doi:10.1016/j.bushor.2009.10.007.
https://psnet.ahrq.gov/issue/mistake-proofing-healthcare-why-stopp…
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psnet.ahrq.gov/node/39634/psn-pdf
December 04, 2016 - We meant no harm, yet we made a mistake; why not
apologize for it? A student's view.
December 4, 2016
Sanford DE, Fleming DA. We meant no harm, yet we made a mistake; why not apologize for it? A student's
view. HEC Forum. 2010;22(2):159-69. doi:10.1007/s10730-010-9131-8.
https://psnet.ahrq.gov/issue/we-meant-no-ha…