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psnet.ahrq.gov/issue/seven-potentially-deadly-prescribing-errors
June 12, 2013 - Newspaper/Magazine Article
Seven (potentially) deadly prescribing errors.
Citation Text:
Seven (potentially) deadly prescribing errors. Graham LR, Scudder L, Stokowski L. Medscape. October 22, 2015.
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psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report
July 18, 2018 - Book/Report
Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report.
Citation Text:
Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. Cambridge, MA: CRICO Strategies; 2016.
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psnet.ahrq.gov/issue/safety-i-and-safety-ii-past-and-future-safety-management
July 22, 2019 - Book/Report
Classic
Safety-I and Safety-II: The Past and Future of Safety Management.
Citation Text:
Safety-I and Safety-II: The Past and Future of Safety Management. Hollnagel E. Aldershot, Hampshire, England: Ashgate; 2014. ISBN: 9781472423085.
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psnet.ahrq.gov/issue/advancing-safety-closed-loop-communication-test-results
November 13, 2019 - Newspaper/Magazine Article
Advancing safety with closed-loop communication of test results.
Citation Text:
Advancing safety with closed-loop communication of test results. Quick Safety. December 17, 2019;(52):1-3.
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psnet.ahrq.gov/issue/error-rate-greatest-hospital-radiology
December 24, 2008 - Newspaper/Magazine Article
Error rate greatest in hospital radiology.
Citation Text:
Error rate greatest in hospital radiology. Stein R; USP; United States Pharmacopeia
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psnet.ahrq.gov/issue/conversation-patient-safety-officers
April 30, 2024 - Book/Report
A Conversation with Patient Safety Officers.
Citation Text:
A Conversation with Patient Safety Officers. Harrisburg, PA: Patient Safety Authority; 2007.
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psnet.ahrq.gov/issue/why-accountability-sharing-health-care-organizational-cultures-means-patients-are-probably
May 27, 2020 - Commentary
Why accountability sharing in health care organizational cultures means patients are probably safer.
Citation Text:
Why accountability sharing in health care organizational cultures means patients are probably safer. Eng DM, Schweikart SJ. AMA J Ethics. 2020;22(9):e779-e783.
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psnet.ahrq.gov/node/853902/psn-pdf
September 27, 2023 - by or on patients” and relevant
financial relationships as “financial relationships in any amount occurring
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - used by or on patients” and relevant financial relationships as “financial relationships in any amount occurring
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - The Commentary
Background Errors in laboratory services encompass a number of problems occurring outside … often attribute to errors inside the laboratory, are actually the result of preanalytic problems occurring … Specific Errors in This Case The particular error in this case is a mislabeling error occurring outside
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psnet.ahrq.gov/node/836976/psn-pdf
April 27, 2022 - or used on patients” and relevant financial
relationships as “financial relationships in any amount occurring
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psnet.ahrq.gov/node/60066/psn-pdf
March 25, 2020 - or used on patients” and relevant financial
relationships as “financial relationships in any amount occurring
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - Crossed Coverage
Citation Text:
Kayser SR. Crossed Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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…
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary …
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - One Bronchoscopy, Two Errors
Citation Text:
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
May 01, 2017 - Wrong Turn through Colon: Misplaced PEG
Citation Text:
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. 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/web-mm/hard-swallow
April 26, 2023 - Hard to Swallow
Citation Text:
Driver J. Hard to Swallow. 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/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/49411/psn-pdf
July 01, 2003 - Code Status Confusion
July 1, 2003
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/code-status-confusion
Case Objectives
Appreciate challenges of determining goals of care in hospitalized patients
Understand patients’ common misconceptions about CPR
List typical mist…
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psnet.ahrq.gov/web-mm/infused-not-ingested
February 01, 2017 - Infused, Not Ingested
Citation Text:
Foley M. Infused, Not Ingested. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …