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psnet.ahrq.gov/node/45819/psn-pdf
March 15, 2017 - How doctors think: common diagnostic errors in clinical
judgment--lessons from an undiagnosed and rare disease
program.
March 15, 2017
Kliegman RM, Bordini BJ, Basel D, et al. How Doctors Think: Common Diagnostic Errors in Clinical
Judgment-Lessons from an Undiagnosed and Rare Disease Program. Pediatr Clin North A…
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psnet.ahrq.gov/node/837060/psn-pdf
May 11, 2022 - Clinician distress and inappropriate antibiotic prescribing
for acute respiratory tract infections: a retrospective
cohort study.
May 11, 2022
Brady KJS, Barlam TF, Trockel MT, et al. Clinician distress and inappropriate antibiotic prescribing for
acute respiratory tract infections: a retrospective cohort study. J…
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psnet.ahrq.gov/node/42513/psn-pdf
January 15, 2014 - A comprehensive patient safety program can significantly
reduce preventable harm, associated costs, and hospital
mortality.
January 15, 2014
Brilli RJ, McClead RE, Crandall W, et al. A comprehensive patient safety program can significantly reduce
preventable harm, associated costs, and hospital mortality. J Pediat…
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psnet.ahrq.gov/node/847049/psn-pdf
April 05, 2023 - Effects of racial bias in pulse oximetry on children and
how to address algorithmic bias in clinical medicine.
April 5, 2023
Gray KD, Subramaniam HL, Huang ES. Effects of racial bias in pulse oximetry on children and how to
address algorithmic bias in clinical medicine. JAMA Pediatr. 2023;177(5):459-460.
doi:10.10…
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psnet.ahrq.gov/node/46982/psn-pdf
June 13, 2018 - Advances in perioperative quality and safety.
June 13, 2018
Anderson KT, Appelbaum R, Bartz-Kurycki MA, et al. Advances in perioperative quality and safety. Semin
Pediatr Surg. 2018;27(2):92-101. doi:10.1053/j.sempedsurg.2018.02.006.
https://psnet.ahrq.gov/issue/advances-perioperative-quality-and-safety
Clinical s…
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psnet.ahrq.gov/node/60600/psn-pdf
June 17, 2020 - Reasons for drug administration problems and perceived
needs for assistance of patients, family caregivers, and
nurses: a qualitative study.
June 17, 2020
Lampert A, Haefeli WE, Seidling HM. Reasons for drug administration problems and perceived needs for
assistance of patients, family caregivers, and nurses: a qu…
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psnet.ahrq.gov/node/866283/psn-pdf
July 10, 2024 - Safety and Quality of Parenteral Nutrition: Translating
Guidelines into Clinical Practice Considering Different
Organizational Settings.
July 10, 2024
Am J Health Syst Pharm. 2024;81(supp 3):s73-s136.
https://psnet.ahrq.gov/issue/safety-and-quality-parenteral-nutrition-translating-guidelines-clinical-practice-
co…
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psnet.ahrq.gov/node/45179/psn-pdf
July 13, 2016 - Communication and shared understanding between
parents and resident-physicians at night.
July 13, 2016
Khan A, Rogers JE, Forster CS, et al. Communication and Shared Understanding Between Parents and
Resident-Physicians at Night. Hosp Pediatr. 2016;6(6):319-29. doi:10.1542/hpeds.2015-0224.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/45138/psn-pdf
May 25, 2016 - Improving Weekend Out Of Hours Surgical Handover
(WOOSH).
May 25, 2016
Boyer M, Tappenden J, Peter M. Improving Weekend Out Of hours Surgical Handover (WOOSH). BMJ
Qual Improv Rep. 2016;5(1):1-4. doi:10.1136/bmjquality.u209552.w4190.
https://psnet.ahrq.gov/issue/improving-weekend-out-hours-surgical-handover-woosh
…
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psnet.ahrq.gov/node/838088/psn-pdf
September 14, 2022 - 'We had such trust, we feel such fools’: how shocking
hospital mistakes led to our daughter’s death.
September 14, 2022
Mills M. The Guardian. September 3, 2022.
https://psnet.ahrq.gov/issue/we-had-such-trust-we-feel-such-fools-how-shocking-hospital-mistakes-led-our-
daughters-death
Families experiencing medical …
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psnet.ahrq.gov/node/46965/psn-pdf
March 28, 2018 - The other opioid crisis: hospital shortages lead to patient
pain, medical errors.
March 28, 2018
Bartolone P. Kaiser Health News. March 16, 2018.
https://psnet.ahrq.gov/issue/other-opioid-crisis-hospital-shortages-lead-patient-pain-medical-errors
Drug shortages may require clinicians, pharmacists, and hospitals to…
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psnet.ahrq.gov/node/60359/psn-pdf
May 20, 2020 - Incorrect use of smart infusion pump in the operating
room (OR) leads to milrinone overdose.
May 20, 2020
ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9).
https://psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone-
overdose
Lack of familiarity with sm…
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psnet.ahrq.gov/node/50708/psn-pdf
December 04, 2019 - Identifying medication errors in neonatal intensive care
units: a two-center study
December 4, 2019
Eslami K, Aletayeb F, Aletayeb SMH, et al. Identifying medication errors in neonatal intensive care units: a
two-center study. BMC Pediatr. 2019;19(1):365. doi:10.1186/s12887-019-1748-4.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/45816/psn-pdf
February 01, 2017 - Parent preferences for medical error disclosure: a
qualitative study.
February 1, 2017
Coffey M, Espin S, Hahmann T, et al. Parent Preferences for Medical Error Disclosure: A Qualitative Study.
Hosp Pediatr. 2017;7(1):24-30. doi:10.1542/hpeds.2016-0048.
https://psnet.ahrq.gov/issue/parent-preferences-medical-error…
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psnet.ahrq.gov/node/46861/psn-pdf
February 28, 2018 - Special K with no license to kill: accidental ketamine
overdose on induction of general anesthesia.
February 28, 2018
Warner LL, Smischney N. Accidental Ketamine Overdose on Induction of General Anesthesia. Am J Case
Rep. 2018;19:10-12.
https://psnet.ahrq.gov/issue/special-k-no-license-kill-accidental-ketamine-ove…
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psnet.ahrq.gov/node/33748/psn-pdf
April 01, 2013 - Landrigan, MD, is Associate Professor of Medicine and Pediatrics at
Harvard Medical School and Director … But in pediatrics, internal medicine, and family practice, it represented more of a minor
rearrangement
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psnet.ahrq.gov/issue/electronic-health-record-based-real-time-analytics-program-patient-safety-surveillance-and
May 19, 2018 - Study
An electronic health record–based real-time analytics program for patient safety surveillance and improvement.
Citation Text:
Classen D, Li M, Miller S, et al. An Electronic Health Record-Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement. Health Aff …
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psnet.ahrq.gov/issue/clinical-characteristics-and-short-term-outcomes-acute-kidney-injury-missed-diagnosis-older
April 20, 2022 - Study
Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.
Citation Text:
Li Q, Hu P, Kang H, et al. Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis…
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psnet.ahrq.gov/issue/physician-intent-pharmacy-label-prevalence-and-description-discrepancies-cross-sectional
July 22, 2020 - Study
From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions.
Citation Text:
Cochran GL, Klepser DG, Morien M, et al. From physician intent to the pharmacy label: prevalence and description o…
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psnet.ahrq.gov/issue/barriers-and-facilitators-healthcare-workers-adherence-infection-prevention-and-control-ipc
March 02, 2011 - Review
Classic
Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis.
Citation Text:
Houghton C, Meskell P, Delaney H, et al. …