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psnet.ahrq.gov/node/49792/psn-pdf
May 01, 2017 - Diagnostic Delay in the Emergency Department
May 1, 2017
Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
Case Objectives
Appreciate the importance of a broad differential diagnosis for acute abdominal pai…
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psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - Hidden Heparins: HIT Happens
December 1, 2006
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
Case Objectives
Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication,
thrombosis.
Discuss the managem…
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psnet.ahrq.gov/issue/qualitative-content-analysis-retained-surgical-items-learning-root-cause-analysis
December 06, 2023 - Study
A qualitative content analysis of retained surgical items: learning from root cause analysis investigations.
Citation Text:
Hibbert PD, Thomas MJW, Deakin A, et al. A qualitative content analysis of retained surgical items: learning from root cause analysis investigations. Int J Qu…
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psnet.ahrq.gov/issue/risk-factors-retained-surgical-items-meta-analysis-and-proposed-risk-stratification-system
January 18, 2013 - Study
Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system.
Citation Text:
Moffatt-Bruce SD, Cook CH, Steinberg SM, et al. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. J Surg Res. 2014;190(…
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psnet.ahrq.gov/issue/prevalence-and-characteristics-interruptions-and-distractions-during-surgical-counts
March 09, 2016 - Study
Prevalence and characteristics of interruptions and distractions during surgical counts.
Citation Text:
Bubric KA, Biesbroek SL, Laberge JC, et al. Prevalence and characteristics of interruptions and distractions during surgical counts. Jt Comm J Qual Patient Saf. 2021;47(9):556-56…
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psnet.ahrq.gov/issue/use-daily-goals-checklist-morning-icu-rounds-mixed-methods-study
November 21, 2021 - Study
Use of a daily goals checklist for morning ICU rounds: a mixed-methods study.
Citation Text:
Centofanti JE, Duan EH, Hoad NC, et al. Use of a daily goals checklist for morning ICU rounds: a mixed-methods study. Crit Care Med. 2014;42(8):1797-803. doi:10.1097/CCM.0000000000000331.
…
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psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
March 01, 2004 - seen increased interest in developing validated assessment tools, which should lay a foundation for objective
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psnet.ahrq.gov/issue/handoff-strategies-settings-high-consequences-failure-lessons-health-care-operations
March 14, 2018 - Study
Classic
Handoff strategies in settings with high consequences for failure: lessons for health care operations.
Citation Text:
Patterson ES. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual …
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psnet.ahrq.gov/issue/prevention-retained-surgical-sponges-decision-analytic-model-predicting-relative-cost
January 04, 2010 - Study
Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness.
Citation Text:
Regenbogen SE, Greenberg CC, Resch SC, et al. Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness. Surger…
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psnet.ahrq.gov/node/36247/psn-pdf
February 13, 2008 - Counting for patient safety.
February 13, 2008
Watson DS. Counting for patient safety. AORN J. 2006;84(2):273-5.
https://psnet.ahrq.gov/issue/counting-patient-safety
The author discusses recommended policies and practices for minimizing the risk of retained foreign
objects.
https://psnet.ahrq.gov/issue/counting-p…
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psnet.ahrq.gov/issue/frequency-and-significance-discrepancies-surgical-count
March 02, 2011 - Study
The frequency and significance of discrepancies in the surgical count.
Citation Text:
Greenberg CC, Regenbogen SE, Lipsitz SR, et al. The Frequency and Significance of Discrepancies in the Surgical Count. Ann Surg. 2009;248(2). doi:10.1097/sla.0b013e318181c9a3.
Copy Citation
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psnet.ahrq.gov/issue/using-data-matrix-coded-sponge-counting-system-across-surgical-practice-impact-after-18
January 02, 2017 - Study
Using a data-matrix–coded sponge counting system across a surgical practice: impact after 18 months.
Citation Text:
Cima RR, Kollengode A, Clark J, et al. Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months. Jt Comm J Qual Patient S…
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psnet.ahrq.gov/issue/role-radio-frequency-detection-system-embedded-surgical-sponges-preventing-retained-surgical
February 13, 2008 - Study
The role of radio frequency detection system embedded surgical sponges in preventing retained surgical sponges: a prospective evaluation in patients undergoing emergency surgery.
Citation Text:
Inaba K, Okoye O, Aksoy H, et al. The Role of Radio Frequency Detection System Embedded …
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psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-preventable-complications
January 22, 2014 - Commentary
Classic
The wisdom and justice of not paying for "preventable complications."
Citation Text:
Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.1…
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psnet.ahrq.gov/node/35406/psn-pdf
September 10, 2009 - Maintain accountability in patient safety efforts.
September 10, 2009
Spath P. Maintain accountability in patient safety efforts. Hospital peer review. 2005;30(9):129-32.
https://psnet.ahrq.gov/issue/maintain-accountability-patient-safety-efforts
To develop an accountability initiative, the author recommends settin…
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psnet.ahrq.gov/node/35288/psn-pdf
September 12, 2016 - M.R.I.'s strong magnets cited in accidents.
September 12, 2016
McNeil DG, Jr.
https://psnet.ahrq.gov/issue/mris-strong-magnets-cited-accidents
This front page article in The New York Times reviews flying object incidents in magnetic resonance
imaging (MRI) scanners. A number of dramatic cases are described (includ…
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psnet.ahrq.gov/issue/risk-factors-and-outcomes-foreign-body-left-during-procedure-analysis-413-incidents-after
December 04, 2016 - Study
Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1,946,831 operations in children.
Citation Text:
Camp M, Chang DC, Zhang Y, et al. Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after…
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psnet.ahrq.gov/issue/managing-prevention-retained-surgical-instruments-what-value-counting
September 25, 2008 - Study
Classic
Managing the prevention of retained surgical instruments: what is the value of counting?
Citation Text:
Egorova NN, Moskowitz A, Gelijns A, et al. Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg. …
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psnet.ahrq.gov/issue/surgical-case-listing-accuracy-failure-analysis-high-volume-academic-medical-center
September 25, 2011 - Study
Surgical case listing accuracy: failure analysis at a high-volume academic medical center.
Citation Text:
Cima RR, Hale C, Kollengode A, et al. Surgical case listing accuracy: failure analysis at a high-volume academic medical center. Arch Surg. 2010;145(7):641-6. doi:10.1001/archs…
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psnet.ahrq.gov/issue/how-best-measure-surgical-quality-comparison-agency-healthcare-research-and-quality-patient
December 21, 2014 - Study
How best to measure surgical quality? Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution.
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