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psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans.
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psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cybersecurity
March 27, 2024 - Sarah Mossburg: What are some mistakes that organizations might make when it comes to their cybersecurity
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psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
March 27, 2024 - Sarah Mossburg: What are some mistakes that organizations might make when it comes to their cybersecurity
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psnet.ahrq.gov/node/49719/psn-pdf
September 01, 2014 - No BP During NIBP
September 1, 2014
Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/no-bp-during-nibp
The Case
An otherwise healthy 49-year-old man with atrial fibrillation was scheduled for ablation in the catheterization
laboratory under general endotracheal anes…
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psnet.ahrq.gov/node/49517/psn-pdf
August 01, 2006 - Miscalculated Risk
August 1, 2006
Strassels SA. Miscalculated Risk. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/miscalculated-risk
The Case
A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after lifting his 2-
week-old infant. He received Vicodin (hydrocodone and a…
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psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
February 01, 2012 - Febrile Neutropenia and an Almost Fatal Medication Error
Citation Text:
Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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…
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psnet.ahrq.gov/node/33700/psn-pdf
October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD
October 1, 2010
In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
Editor's note: Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and He…
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psnet.ahrq.gov/node/49436/psn-pdf
February 26, 2004 - Transfusion "Slip"
February 1, 2004
Kaplan HS. Transfusion "Slip". PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/transfusion-slip
The Case
A married couple, Mr. and Mrs. M, was brought to the emergency department (ED) of a Level 1 trauma
center after a half-ton truck that had skidded out of control struck…
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psnet.ahrq.gov/node/49637/psn-pdf
October 01, 2011 - The Dropped "No"
October 1, 2011
Johnson AJ. The Dropped "No". PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropped-no
The Case
A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in
his legs. Because the leg swelling was somewhat more pronounced in his…
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psnet.ahrq.gov/web-mm/workaround-error
October 30, 2024 - Workaround Error
Citation Text:
Pape T. Workaround Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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…
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psnet.ahrq.gov/web-mm/dangerous-dapsone
January 10, 2011 - Dangerous Dapsone
Citation Text:
Bookwalter T. Dangerous Dapsone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/turn-other-cheek
October 26, 2010 - Turn the Other Cheek
Citation Text:
Starling J. Turn the Other Cheek. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/33822/psn-pdf
January 01, 2017 - and the pharmacy and the prep process
and the pharmacy and the delivery process to the ward and the mistakes
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psnet.ahrq.gov/node/33744/psn-pdf
February 01, 2013 - So even if the situation was just dreadful, mistakes were made, it was
handled very poorly, can that
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psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - We're in an environment
where stakeholders don't want to pay for our mistakes the way they have in the
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psnet.ahrq.gov/node/33801/psn-pdf
February 01, 2016 - Physicians who are burned out make more mistakes.
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - such as how medications are
manufactured and packaged) and active errors (i.e., slips, lapses, or mistakes … closed-loop communication.
42
Medication error reporting
The safest organizations learn from their mistakes
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - June 16, 2019
WebM&M Cases
Vial Mistakes Involving Heparin
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psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
August 01, 2005 - practice behind the idea of systems, but we must recognize that systems play a huge role in preventing mistakes
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psnet.ahrq.gov/web-mm/volume-too-low-and-out
July 01, 2017 - Hospitals
Health Care Providers
Pediatrics
Medical Complications
Cognitive Errors ("Mistakes