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psnet.ahrq.gov/node/49413/psn-pdf
September 01, 2003 - Did We Forget Something?
September 1, 2003
Gibbs VC. Did We Forget Something? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/did-we-forget-something
The Case
A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially
attributed to ventilator-associated pneumo…
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psnet.ahrq.gov/issue/not-again
August 04, 2021 - Commentary
Not again!
Citation Text:
Berwick D. Not again!. BMJ. 2001;322(7281):247-8.
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psnet.ahrq.gov/issue/patient-physician-racial-and-ethnic-concordance-and-perceived-medical-errors
July 27, 2022 - Commentary
Patient-physician racial and ethnic concordance and perceived medical errors.
Citation Text:
Stepanikova I. Patient-physician racial and ethnic concordance and perceived medical errors. Social Sci Med. 2006;63(12):3060-3066.
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psnet.ahrq.gov/issue/health-life-keys-safer-hospitals
August 04, 2021 - Newspaper/Magazine Article
Health for life. Keys to safer hospitals.
Citation Text:
Berwick DM. Health for life. 6 keys to safer hospitals. Newsweek. 2005;146(24):76-8.
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psnet.ahrq.gov/issue/interview-donald-berwick
August 04, 2021 - Commentary
An interview with Donald Berwick.
Citation Text:
Berwick DM. An interview with Donald Berwick. Interview by Paul M Schyve. Jt Comm J Qual Patient Saf. 2006;32(12):661-666.
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psnet.ahrq.gov/node/42788/psn-pdf
January 19, 2014 - Demonstrating high reliability on accountability measures
at The Johns Hopkins Hospital.
January 19, 2014
Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the
Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531-544.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/issue/organizational-and-intraorganizational-development-disasters
May 12, 2021 - Review
Classic
The organizational and intraorganizational development of disasters.
Citation Text:
Turner BA. The Organizational and Interorganizational Development of Disasters. Adm Sci Q. 1976;21(3):378. doi:10.2307/2391850.
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psnet.ahrq.gov/issue/medical-errors-education-prospective-study-new-educational-tool
March 20, 2024 - Study
Medical errors education: a prospective study of a new educational tool.
Citation Text:
Paxton JH, Rubinfeld IS. Medical errors education: A prospective study of a new educational tool. Am J Med Qual. 2010;25(2):135-42. doi:10.1177/1062860609353345.
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psnet.ahrq.gov/issue/enhancing-patient-safety-improving-patient-handoff-process-through-appreciative-inquiry
April 10, 2024 - Commentary
Enhancing patient safety: improving the patient handoff process through appreciative inquiry.
Citation Text:
Shendell-Falik N, Feinson M, Mohr BJ. Enhancing patient safety: improving the patient handoff process through appreciative inquiry. J Nurs Adm. 2007;37(2):95-104.
C…
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psnet.ahrq.gov/issue/effectiveness-computerized-provider-order-entry-dose-range-checking-prescribing-errors
October 23, 2024 - Study
Effectiveness of computerized provider order entry with dose range checking on prescribing errors.
Citation Text:
Boling B, McKibben M, Hingl J, et al. Effectiveness of Computerized Provider Order Entry with Dose Range Checking on Prescribing Errors. J Patient Saf. 2008;1(4). doi…
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psnet.ahrq.gov/issue/redesigning-morbidity-and-mortality-program-university-affiliated-pediatric-anesthesia
March 27, 2024 - Commentary
Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department.
Citation Text:
McDonnell C, Laxer RM, Roy L. Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department. Jt Comm J Qual Pat…
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psnet.ahrq.gov/node/33607/psn-pdf
September 27, 2022 - 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/49737/psn-pdf
June 01, 2015 - perform intermittent
catheterizations frequently (e.g., spinal cord injury patients), but it can also be produced
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - 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/what-patient-centered-should-mean-confessions-extremist
August 04, 2021 - Commentary
What 'patient-centered' should mean: confessions of an extremist.
Citation Text:
Berwick DM. What 'patient-centered' should mean: confessions of an extremist. Health Aff (Millwood). 2009;28(4):w555-65. doi:10.1377/hlthaff.28.4.w555.
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psnet.ahrq.gov/issue/chemotherapy-error-practical-approaches-increasing-patient-safety
August 04, 2021 - Commentary
Chemotherapy error: practical approaches to increasing patient safety.
Citation Text:
Harris TJ, Northfelt DW. Chemotherapy Error. J Patient Saf. 2008;1(4). doi:10.1097/01.jps.0000215340.80935.d0.
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psnet.ahrq.gov/issue/medicines-shadowside-revisiting-clinical-iatrogenesis
September 08, 2021 - Special or Theme Issue
Medicine's Shadowside: Revisiting Clinical Iatrogenesis.
Citation Text:
Medicine's Shadowside: Revisiting Clinical Iatrogenesis. Varley E, Varma S, eds. Anthropol Med. 2021;28(2);141-278.
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psnet.ahrq.gov/issue/err-human-quality-and-safety-issues-spine-care
August 04, 2021 - Commentary
To err is human: quality and safety issues in spine care.
Citation Text:
Wong DA, Watters WC. To err is human: quality and safety issues in spine care. Spine (Phila Pa 1976). 2007;32(11 Suppl):S2-8.
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psnet.ahrq.gov/node/43708/psn-pdf
May 28, 2015 - The impact of time at work and time off from work on rule
compliance: the case of hand hygiene in health care.
May 28, 2015
Dai H, Milkman KL, Hofmann DA, et al. The impact of time at work and time off from work on rule
compliance: the case of hand hygiene in health care. J Appl Psychol. 2015;100(3):846-62.
doi:10…
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psnet.ahrq.gov/issue/patient-safety-crossroads
March 18, 2019 - Commentary
Patient safety at the crossroads.
Citation Text:
Gandhi TK, Berwick DM, Shojania KG. Patient Safety at the Crossroads. JAMA. 2016;315(17):1829-30. doi:10.1001/jama.2016.1759.
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