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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.104_slideshow.ppt
September 01, 2005 - Robert Wachter, MD
Spotlight Editor: Tracy Minichiello, MD
Managing Editor: Erin Hartman, MS
Objectives
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
November 01, 2003 - Robert Wachter, MD
Spotlight Editor: Tracy Minichiello, MD
Managing Editor: Erin Hartman, MS
Objectives
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psnet.ahrq.gov/node/42660/psn-pdf
October 16, 2013 - Practice indicators of suboptimal care and avoidable
adverse events: a content analysis of a national qualifying
examination.
October 16, 2013
Bordage G, Meguerditchian A-N, Tamblyn R. Practice indicators of suboptimal care and avoidable adverse
events: a content analysis of a national qualifying examination. Acad…
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psnet.ahrq.gov/node/35574/psn-pdf
June 17, 2010 - What do we know about financial returns on investments
in patient safety? A literature review.
June 17, 2010
Schmidek JM, Weeks WB. What do we know about financial returns on investments in patient safety? A
literature review. Jt Comm J Qual Patient Saf. 2005;31(12):690-699.
https://psnet.ahrq.gov/issue/what-do-we…
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psnet.ahrq.gov/node/49797/psn-pdf
June 01, 2017 - Diagnostic Overshadowing Dangers
June 1, 2017
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
The Case
A 72-year-old woman with history of opioid abuse was sent to the emergency department (ED) from a
methadone clinic because she a…
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psnet.ahrq.gov/node/33786/psn-pdf
May 01, 2015 - Video to Improve Patient Safety: Clinical and Educational
Uses
May 1, 2015
Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient Safety: Clinical and Educational Uses. PSNet
[internet]. 2015.
https://psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
Perspective
Reports of…
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psnet.ahrq.gov/node/60047/psn-pdf
March 18, 2020 - A systematic review exploring the content and outcomes
of interventions to improve psychological safety,
speaking up and voice behaviour.
March 18, 2020
O’Donovan R, McAuliffe E. A systematic review exploring the content and outcomes of interventions to
improve psychological safety, speaking up and voice behaviour…
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psnet.ahrq.gov/node/73131/psn-pdf
April 14, 2021 - Identification of common themes from never events data
published by NHS England.
April 14, 2021
Omar I, Graham Y, Singhal R, et al. Identification of common themes from never events data published by
NHS England. World J Surg. 2021;45(3):697-704. doi:10.1007/s00268-020-05867-7.
https://psnet.ahrq.gov/issue/identif…
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psnet.ahrq.gov/node/851352/psn-pdf
July 12, 2023 - Identifying a list of healthcare 'never events' to effect
system change: a systematic review and narrative
synthesis.
July 12, 2023
Bowman CL, De Gorter R, Zaslow J, et al. Identifying a list of healthcare ‘never events’ to effect system
change: a systematic review and narrative synthesis. BMJ Open Qual. 2023;12(2…
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psnet.ahrq.gov/node/41740/psn-pdf
October 10, 2012 - Effectiveness of a radiofrequency detection system as an
adjunct to manual counting protocols for tracking
surgical sponges: a prospective trial of 2,285 patients.
October 10, 2012
Rupp CC, Kagarise MJ, Nelson SM, et al. Effectiveness of a radiofrequency detection system as an adjunct
to manual counting protocols …
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psnet.ahrq.gov/node/45234/psn-pdf
November 18, 2016 - Recommended responsibilities for management of MR
safety.
November 18, 2016
Calamante F, Ittermann B, Kanal E, et al. Recommended responsibilities for management of MR safety. J
Magn Reson Imaging. 2016;44(5):1067-1069. doi:10.1002/jmri.25282.
https://psnet.ahrq.gov/issue/recommended-responsibilities-management-mr…
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psnet.ahrq.gov/node/39356/psn-pdf
April 08, 2011 - Team training in the neonatal resuscitation program for
interns: teamwork and quality of resuscitations.
April 8, 2011
Thomas EJ, Williams AL, Reichman EF, et al. Team training in the neonatal resuscitation program for
interns: teamwork and quality of resuscitations. Pediatrics. 2010;125(3):539-546. doi:10.1542/ped…
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psnet.ahrq.gov/node/46900/psn-pdf
August 29, 2018 - Developing agreement on never events in primary care
dentistry: an international eDelphi study.
August 29, 2018
Ensaldo-Carrasco E, Carson-Stevens A, Cresswell K, et al. Developing agreement on never events in
primary care dentistry: an international eDelphi study. Br Dent J. 2018;224(9):733-740.
doi:10.1038/sj.bd…
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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - Diagnostic Overshadowing Dangers
Citation Text:
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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psnet.ahrq.gov/node/43518/psn-pdf
September 24, 2014 - Natural history of retained surgical items supports the
need for team training, early recognition, and prompt
retrieval.
September 24, 2014
Stawicki P, Cook CH, Anderson HL, et al. Natural history of retained surgical items supports the need for
team training, early recognition, and prompt retrieval. Am J Surg. 20…
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - Case Objectives
List the patient safety events that are unique to inpatient psychiatry. … PubMedId RIS
Download Citation
Submit Your Case
Sections
Case Objectives
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psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - Case Objectives Recognize the importance of a comprehensive, personalized discussion of code status with … PubMedId RIS
Download Citation
Submit Your Case
Sections
Case Objectives
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psnet.ahrq.gov/node/60246/psn-pdf
April 22, 2020 - The impact of surgical count technology on retained
surgical items rates in the Veterans Health
Administration.
April 22, 2020
Gunnar W, Soncrant C, Lynn MM, et al. The impact of surgical count technology on retained surgical items
rates in the Veterans Health Administration. J Patient Saf. 2020;16(4):255-258.
do…
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psnet.ahrq.gov/node/60635/psn-pdf
January 01, 2021 - Systemic defenses to prevent intravenous medication
errors in hospitals: a systematic review.
July 1, 2020
Kuitunen SK, Niittynen I, Airaksinen M, et al. Systemic Defenses to Prevent Intravenous Medication Errors
in Hospitals. J Patient Saf. 2021;17(8):e1669-e1680. doi:10.1097/pts.0000000000000688.
https://psnet.a…
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psnet.ahrq.gov/node/45112/psn-pdf
July 01, 2016 - Surgical count process for prevention of retained surgical
items: an integrative review.
July 1, 2016
Freitas PS, Silveira RC de CP, Clark AM, et al. Surgical count process for prevention of retained surgical
items: an integrative review. J Clin Nurs. 2016;25(13-14):1835-47. doi:10.1111/jocn.13216.
https://psnet.a…