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psnet.ahrq.gov/node/45452/psn-pdf
August 24, 2016 - What price must we pay for safety? Excessive cost of
EPINEPHrine auto-injectors leads to error-prone use of
ampuls or vials and unprepared consumers.
August 24, 2016
ISMP Medication Safety Alert! Acute Care Edition. August 11, 2016;21:1-3.
https://psnet.ahrq.gov/issue/what-price-must-we-pay-safety-excessive-cost-e…
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psnet.ahrq.gov/node/33857/psn-pdf
July 01, 2012 - So the radiology group went to work with the IT group and they produced this application called
radiology
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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - by medical management (rather than the underlying disease) and that prolonged the
hospitalization, produced
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psnet.ahrq.gov/primer/burnout
November 20, 2024 - Committee for Patient Safety co-led with the Agency for Healthcare Research and Quality (AHRQ), which produced … The Mayo Clinic produced a detailed guide for implementing organizational strategies to prevent and
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psnet.ahrq.gov/node/36380/psn-pdf
February 28, 2011 - Graduate medical education and patient safety: a busy--
and occasionally hazardous--intersection.
February 28, 2011
Shojania KG, Fletcher KE, Saint S. Graduate medical education and patient safety: a busy--and
occasionally hazardous--intersection. Ann Intern Med. 2006;145(8):592-8.
https://psnet.ahrq.gov/issue/gra…
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psnet.ahrq.gov/node/35434/psn-pdf
June 14, 2011 - Turning the medical gaze in upon itself: root cause
analysis and the investigation of clinical error.
June 14, 2011
Iedema RAM, Jorm C, Long D, et al. Turning the medical gaze in upon itself: root cause analysis and the
investigation of clinical error. Soc Sci Med. 2006;62(7):1605-15.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
April 26, 2023 - Mayo has a great paper that demonstrates that their version of RPI has consistently produced a 5-to
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psnet.ahrq.gov/issue/when-bone-flap-hits-floor
March 12, 2025 - Study
When the bone flap hits the floor.
Citation Text:
Jankowitz BT, Kondziolka DS. When the bone flap hits the floor. Neurosurgery. 2006;59(3):585-90; discussion 585-90.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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psnet.ahrq.gov/issue/when-i-follow-i-dont-give
May 15, 2024 - Newspaper/Magazine Article
When I follow up, I don't give up.
Citation Text:
Roy PJ. When I follow up, I don't give up. Medical economics. 2006;83(15):68-9.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/47787/psn-pdf
February 20, 2019 - How to be a very safe maternity unit: an ethnographic
study.
February 20, 2019
Liberati EG, Tarrant C, Willars J, et al. How to be a very safe maternity unit: An ethnographic study. Soc
Sci Med. 2019;223:64-72. doi:10.1016/j.socscimed.2019.01.035.
https://psnet.ahrq.gov/issue/how-be-very-safe-maternity-unit-ethnog…
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psnet.ahrq.gov/node/34763/psn-pdf
March 07, 2005 - The Limits of Safety: Organizations, Accidents and
Nuclear Weapons.
March 7, 2005
Sagan SD. Princeton NJ: Princeton University Press; 1993. ISBN: 9780691032214.
https://psnet.ahrq.gov/issue/limits-safety-organizations-accidents-and-nuclear-weapons
Two competing paradigms dominate the study of the hazards associate…
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psnet.ahrq.gov/node/33787/psn-pdf
January 01, 2018 - In Conversation With… Maureen Bisognano
June 1, 2015
In Conversation With… Maureen Bisognano. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-maureen-bisognano
Editor's note: Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement
(IHI). We spoke with her about I…
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psnet.ahrq.gov/issue/mbrrace-uk-mothers-and-babies-reducing-risk-through-audits-and-confidential-enquiries-across
July 07, 2021 - Multi-use Website
MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK.
Citation Text:
MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK. Oxford, UK: The National Perinatal Epidemiology U…
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psnet.ahrq.gov/node/50858/psn-pdf
January 31, 2020 - Artificial Intelligence and Diagnostic Errors
January 31, 2020
Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
Definition of Artificial Intelligence
The definition of artificial intelligence (…
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psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
May 01, 2007 - initiated confidential investigations of 5800 cases.( 2 ) National reports on maternal mortality were produced … Since then, it has produced regular reports on all maternal deaths.( 3 ) "Confidential Enquiries" have … I produced a a few years ago to try to introduce an element of no-fault compensation into our system … We have produced guidelines on reporting systems so that people didn't make the mistakes of some of the
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psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
May 01, 2007 - I produced a a few years ago to try to introduce an element of no-fault compensation into our system … We have produced guidelines on reporting systems so that people didn't make the mistakes of some of the … initiated confidential investigations of 5800 cases.( 2 ) National reports on maternal mortality were produced … Since then, it has produced regular reports on all maternal deaths.( 3 ) "Confidential Enquiries" have
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psnet.ahrq.gov/node/33731/psn-pdf
June 01, 2012 - reports: the Institute of Medicine's (IOM) To Err is Human and the UK's An Organisation
with a Memory, produced … Health.(4,5) As British safety expert Professor Charles
Vincent points out, the fact that To Err was produced
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psnet.ahrq.gov/node/33650/psn-pdf
May 01, 2007 - initiated confidential investigations of 5800 cases.(2) National reports on maternal
mortality were produced … Since then, it has produced regular reports on all maternal deaths.(3) "Confidential
Enquiries" have
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psnet.ahrq.gov/node/49489/psn-pdf
September 01, 2005 - systematically analyze its root
causes, using an instrument such as the Medication Discrepancy Tool (Figure) produced … Medication Discrepancy Tool Produced by Care Transitions Program at University of
Colorado at Denver
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psnet.ahrq.gov/issue/making-healthcare-safer-iv-continuous-updating-patient-safety-harms-and-practices
December 10, 2024 - Book/Report
Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.
Citation Text:
Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices. Rockville, MD: Agency for Healthcare Research and Quality: July 2023 - Jan 2025.
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