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psnet.ahrq.gov/issue/medical-misdiagnoses-can-have-fatal-consequences
July 27, 2011 - Newspaper/Magazine Article
Medical misdiagnoses can have fatal consequences.
Citation Text:
Medical misdiagnoses can have fatal consequences. Olsen D. State Journal-Register. June 26, 2011.
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psnet.ahrq.gov/issue/their-kids-died-psych-ward-they-were-far-alone-times-investigation-found
July 20, 2011 - Newspaper/Magazine Article
Their kids died on the psych ward. They were far from alone, a Times investigation found.
Citation Text:
Their kids died on the psych ward. They were far from alone, a Times investigation found. Karlamangla S. Los Angeles Times. December 1, 2019.
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psnet.ahrq.gov/issue/defusing-disruptive-behavior-workbook-health-care-leaders
April 24, 2007 - Book/Report
Defusing Disruptive Behavior. A Workbook for Health Care Leaders.
Citation Text:
Defusing Disruptive Behavior. A Workbook for Health Care Leaders. Oakbrook, IL: Joint Commission Resources; 2007. ISBN: 9781599400846.
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psnet.ahrq.gov/issue/focus-patient-safety
January 23, 2008 - Book/Report
Focus on Patient Safety.
Citation Text:
Focus on Patient Safety. Annu Rev Nurs Res. 2006;24:1-331.
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psnet.ahrq.gov/issue/risk-medication-errors-hospital-discharge-and-barriers-problem-resolution
November 03, 2015 - Study
Risk of medication errors at hospital discharge and barriers to problem resolution.
Citation Text:
Risk of medication errors at hospital discharge and barriers to problem resolution. Enguidanos SM; Brumley RD.
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psnet.ahrq.gov/issue/safety-management-different-high-risk-domains-all-same
September 11, 2024 - Commentary
Safety management in different high-risk domains--all the same?
Citation Text:
Grote G. Safety management in different high-risk domains – All the same? Safety Sci. 2011;50(10):1983-1992. doi:10.1016/j.ssci.2011.07.017.
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psnet.ahrq.gov/issue/optimizing-patient-safety-through-system-strategies-and-patient-engagement
June 22, 2016 - Newspaper/Magazine Article
Optimizing patient safety through system strategies and patient engagement.
Citation Text:
Optimizing patient safety through system strategies and patient engagement. Rooprai P, Mistry N. Patient Saf Qual Healthc. June 23, 2020.
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psnet.ahrq.gov/issue/colorado-mom-story-daughters-hospital-death-key-others-safety
March 07, 2018 - Newspaper/Magazine Article
For Colorado mom, story of daughter's hospital death is key to others' safety.
Citation Text:
For Colorado mom, story of daughter's hospital death is key to others' safety. Daley J. Colorado Public Radio. February 17, 2015.
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psnet.ahrq.gov/issue/patients-put-risk-nhs-computer-fault
November 04, 2012 - Newspaper/Magazine Article
Patients put at risk by NHS computer fault.
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Patients put at risk by NHS computer fault. Gray R.
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psnet.ahrq.gov/issue/alarm-interventions-during-medical-telemetry-monitoring-failure-mode-effects-analysis
March 18, 2010 - Special or Theme Issue
Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis.
Citation Text:
Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis. PA-PSRS Patient Saf Advis. March 2008;5(suppl rev):1-50. …
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psnet.ahrq.gov/issue/distributing-cognition-icu-handoffs-conform-grices-maxims
May 09, 2015 - Image/Poster
Distributing Cognition: ICU Handoffs Conform to Grice's Maxims.
Citation Text:
Distributing Cognition: ICU Handoffs Conform to Grice's Maxims. Brandwijk M; Nemeth C; O'Conner M; Kahana M; Cook RI
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psnet.ahrq.gov/issue/surgical-patient-safety-essential-information-surgeons-todays-environment
October 15, 2018 - Book/Report
Surgical Patient Safety Essential Information for Surgeons in Today's Environment.
Citation Text:
Surgical Patient Safety Essential Information for Surgeons in Today's Environment. Manuel BM, Nora PF, eds. Chicago, IL: American College of Surgeons; 2004. ISBN 978188069616…
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psnet.ahrq.gov/issue/surgery-safer-teaching-hospital
September 28, 2016 - Newspaper/Magazine Article
Is surgery safer at a teaching hospital?
Citation Text:
Is surgery safer at a teaching hospital? Webster H. US News & World Report. October 27, 2014.
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psnet.ahrq.gov/issue/working-knowledge-how-organizations-manage-what-they-know
May 24, 2016 - Book/Report
Working Knowledge: How Organizations Manage What They Know.
Citation Text:
Working Knowledge: How Organizations Manage What They Know. Davenport TH, Prusak L. Boston MA: Harvard Business School Press; 1998. ISBN: 0875846556.
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psnet.ahrq.gov/issue/beth-israel-cited-residents-long-hours-facing-review-accreditation
August 24, 2016 - Newspaper/Magazine Article
Beth Israel cited for residents' long hours—facing review for accreditation.
Citation Text:
Beth Israel cited for residents' long hours—facing review for accreditation. Kowalczyk L.
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psnet.ahrq.gov/issue/better-care-surgical-patients-recognizing-and-responding-unexpected-save-lives
January 11, 2017 - Image/Poster
Better care for surgical patients: recognizing and responding to the unexpected to save lives.
Citation Text:
Better care for surgical patients: recognizing and responding to the unexpected to save lives. Ghaferi A. IHPI Brief. December 2019. &n…
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psnet.ahrq.gov/issue/interdisciplinary-approach-safer-blood-transfusion
June 01, 2016 - Newspaper/Magazine Article
An interdisciplinary approach to safer blood transfusion.
Citation Text:
An interdisciplinary approach to safer blood transfusion. LaRocco M, Brient K. Patient Saf Qual Healthc. March April 2008.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
August 01, 2015 - even between providers for treatment purposes
Development of these unintended practices in day-to-day operations … to do so, and it helps ensure that misinterpretations of the law do not get embedded into day-to-day operations
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psnet.ahrq.gov/issue/descriptive-study-morbidity-and-mortality-conferences-and-their-conformity-medical-incident
September 28, 2010 - National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations
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psnet.ahrq.gov/issue/human-factor-cardiac-surgery-errors-and-near-misses-high-technology-medical-domain
June 09, 2010 - June 9, 2010
Improving patient safety by identifying latent failures in successful operations