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psnet.ahrq.gov/node/34671/psn-pdf
June 15, 2011 - Confidential clinician-reported surveillance of adverse
events among medical inpatients.
June 15, 2011
Weingart SN, Ship AN, Aronson MD. Confidential clinician-reported surveillance of adverse events among
medical inpatients. J Gen Intern Med. 2003;15(7). doi:10.1046/j.1525-1497.2000.06269.x.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/45148/psn-pdf
April 24, 2018 - Safety of overlapping surgery at a high-volume referral
center.
April 24, 2018
Hyder JA, Hanson KT, Storlie CB, et al. Safety of Overlapping Surgery at a High-volume Referral Center.
Ann Surg. 2017;265(4):639-644. doi:10.1097/SLA.0000000000002084.
https://psnet.ahrq.gov/issue/safety-overlapping-surgery-high-volume…
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psnet.ahrq.gov/node/36346/psn-pdf
April 11, 2011 - Incidence and nature of adverse events during pediatric
sedation/anesthesia for procedures outside the operating
room: report from the Pediatric Sedation Research
Consortium.
April 11, 2011
Cravero JP, Blike G, Beach M, et al. Incidence and nature of adverse events during pediatric
sedation/anesthesia for procedu…
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psnet.ahrq.gov/node/866116/psn-pdf
March 16, 2023 - Future of artificial intelligence applications in cancer care:
a global cross-sectional survey of researchers.
March 16, 2023
Cabral BP, Braga LAM, Syed-Abdul S, et al. Future of artificial intelligence applications in cancer care: a
global cross-sectional survey of researchers. Curr Oncol. 2023;30(3):3432-3446.
d…
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psnet.ahrq.gov/node/43173/psn-pdf
June 04, 2014 - Barriers to the implementation of checklists in the office-
based procedural setting.
June 4, 2014
Shapiro FE, Fernando RJ, Urman RD. Barriers to the implementation of checklists in the office-based
procedural setting. J Healthc Risk Manag. 2014;33(4):35-43. doi:10.1002/jhrm.21141.
https://psnet.ahrq.gov/issue/bar…
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psnet.ahrq.gov/node/44761/psn-pdf
January 06, 2016 - Two fatal cases of accidental intrathecal vincristine
administration: learning from death events.
January 6, 2016
Chotsampancharoen T, Sripornsawan P, Wongchanchailert M. Two fatal cases of accidental intrathecal
vincristine administration: learning from death event. Chemotherapy (Los Angel). 2016;61(2):108-110.
d…
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psnet.ahrq.gov/node/45874/psn-pdf
February 22, 2017 - Ethics in the pediatric emergency department: when
mistakes happen: an approach to the process, evaluation,
and response to medical errors.
February 22, 2017
Dreisinger N, Zapolsky N. Ethics in the Pediatric Emergency Department: When Mistakes Happen: An
Approach to the Process, Evaluation, and Response to Medical…
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psnet.ahrq.gov/node/851200/psn-pdf
July 05, 2023 - Deficient Care of a Patient Who Died by Suicide and
Facility Leaders' Response at the Charlie Norwood VA
Medical Center in Augusta, Georgia.
July 5, 2023
Washington DC: Department of Veterans Affairs, Office of Inspector General; May 10, 2023.
Report no. 22-01116-110.
https://psnet.ahrq.gov/issue/defi…
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psnet.ahrq.gov/node/74206/psn-pdf
December 22, 2021 - Direct oral anticoagulant-related medication incidents and
pharmacists' interventions in hospital in-patients:
evaluation using Reason's accident causation theory.
December 22, 2021
Haque H, Alrowily A, Jalal Z, et al. Direct oral anticoagulant-related medication incidents and pharmacists’
interventions in hospita…
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psnet.ahrq.gov/node/44098/psn-pdf
April 29, 2015 - Evaluation of the suitability of root cause analysis
frameworks for the investigation of community-acquired
pressure ulcers: a systematic review and documentary
analysis.
April 29, 2015
McGraw C, Drennan VM. Evaluation of the suitability of root cause analysis frameworks for the
investigation of community-acquire…
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psnet.ahrq.gov/node/866517/psn-pdf
August 14, 2024 - Feedback loop failure modes in medical diagnosis: how
biases can emerge and be reinforced.
August 14, 2024
Aikens RC, Chen JH, Baiocchi M, et al. Feedback loop failure modes in medical diagnosis: how biases can
emerge and be reinforced. Med Decis Making. 2024;44(5):481-496. doi:10.1177/0272989x241248612.
https://p…
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psnet.ahrq.gov/node/42322/psn-pdf
June 05, 2013 - Delivery of optimized inpatient anticoagulation therapy:
consensus statement from the Anticoagulation Forum.
June 5, 2013
Nutescu EA, Wittkowsky AK, Burnett A, et al. Delivery of optimized inpatient anticoagulation therapy:
consensus statement from the anticoagulation forum. Ann Pharmacother. 2013;47(5):714-24.
do…
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psnet.ahrq.gov/node/47141/psn-pdf
August 17, 2018 - Association of postoperative readmissions with surgical
quality using a Delphi consensus process to identify
relevant diagnosis codes.
August 17, 2018
Mull HJ, Graham LA, Morris MS, et al. Association of Postoperative Readmissions With Surgical Quality
Using a Delphi Consensus Process to Identify Relevant Diagnosi…
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psnet.ahrq.gov/node/60231/psn-pdf
April 15, 2020 - Regret among primary care physicians: a survey of
diagnostic decisions.
April 15, 2020
Müller BS, Donner-Banzhoff N, Beyer M, et al. Regret among primary care physicians: a survey of
diagnostic decisions. BMC Fam Pract. 2020;21(1). doi:10.1186/s12875-020-01125-w.
https://psnet.ahrq.gov/issue/regret-among-primary-c…
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psnet.ahrq.gov/node/37346/psn-pdf
March 28, 2012 - Medication administration discrepancies persist despite
electronic ordering.
March 28, 2012
FitzHenry F, Peterson JF, Arrieta M, et al. Medication Administration Discrepancies Persist Despite
Electronic Ordering. J Am Med Inform Assoc. 2007;14(6):756-764. doi:10.1197/jamia.m2359.
https://psnet.ahrq.gov/issue/medic…
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psnet.ahrq.gov/issue/parent-preferences-medical-error-disclosure-qualitative-study
January 25, 2017 - April 12, 2011
Managing the adverse event occurring during elective, ambulatory pediatric
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psnet.ahrq.gov/issue/emergency-department-boarding-and-adverse-hospitalization-outcomes-among-patients-admitted
July 13, 2016 - June 30, 2021
Analysis of risk factors for patient safety events occurring in the emergency
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psnet.ahrq.gov/issue/adverse-drug-event-nonrecognition-emergency-departments-exploratory-study-factors-related
April 12, 2011 - More
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Systematic evaluation of errors occurring during the preparation of intravenous