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psnet.ahrq.gov/node/844539/psn-pdf
February 15, 2023 - Partnering with patients and families living with chronic
conditions to coproduce diagnostic safety through
OurDX: a previsit online engagement tool.
February 15, 2023
Bell SK, Dong ZJ, DesRoches CM, et al. Partnering with patients and families living with chronic conditions
to coproduce diagnostic safety through …
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psnet.ahrq.gov/node/43090/psn-pdf
November 23, 2016 - Safety Is Personal: Partnering With Patients and Families
for the Safest Care.
November 23, 2016
NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Boston, MA:
National Patient Safety Foundation; March 2014.
https://psnet.ahrq.gov/issue/safety-personal-partnering-patients-and-families…
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psnet.ahrq.gov/node/46756/psn-pdf
May 09, 2018 - Using a modified A3 lean framework to identify ways to
increase students' reporting of mistreatment behaviors.
May 9, 2018
Ross PT, Abdoler E, Flygt LA, et al. Using a Modified A3 Lean Framework to Identify Ways to Increase
Students' Reporting of Mistreatment Behaviors. Acad Med. 2018;93(4):606-611.
doi:10.1097/AC…
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psnet.ahrq.gov/node/73510/psn-pdf
July 21, 2021 - Stroke hospitalization after misdiagnosis of "benign
dizziness" is lower in specialty care than general practice:
a population-based cohort analysis of missed stroke
using SPADE methods.
July 21, 2021
Chang T-P, Bery AK, Wang Z, et al. Stroke hospitalization after misdiagnosis of “benign dizziness” is lower
in sp…
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psnet.ahrq.gov/node/865875/psn-pdf
May 15, 2024 - Digital health interventions and patient safety in
abdominal surgery: a systematic review and meta-
analysis.
May 15, 2024
Grygorian A, Montano D, Shojaa M, et al. Digital health interventions and patient safety in abdominal
surgery: a systematic review and meta-analysis. JAMA Netw Open. 2024;7(4):e248555.
doi:10…
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psnet.ahrq.gov/node/848360/psn-pdf
May 03, 2023 - Optimizing measurement of misdiagnosis-related harms
using symptom-disease pair analysis of diagnostic error
(SPADE): comparison groups to maximize SPADE
validity.
May 3, 2023
Liberman AL, Wang Z, Zhu Y, et al. Optimizing measurement of misdiagnosis-related harms using
symptom-disease pair analysis of diagnostic …
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psnet.ahrq.gov/node/47097/psn-pdf
June 26, 2018 - Patterns of potential opioid misuse and subsequent
adverse outcomes in Medicare, 2008 to 2012.
June 26, 2018
Carey CM, Jena AB, Barnett ML. Patterns of Potential Opioid Misuse and Subsequent Adverse Outcomes
in Medicare, 2008 to 2012. Ann Intern Med. 2018;168(12):837-845. doi:10.7326/M17-3065.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/867177/psn-pdf
January 01, 2025 - Experiences with diagnostic delay among underserved
racial and ethnic patients: a systematic review of the
qualitative literature.
November 20, 2024
Faugno E, Galbraith AA, Walsh KE, et al. Experiences with diagnostic delay among underserved racial and
ethnic patients: a systematic review of the qualitative litera…
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psnet.ahrq.gov/node/45023/psn-pdf
April 17, 2018 - Lean Hospitals: Improving Quality, Patient Safety, and
Employee Engagement, Third Edition.
April 17, 2018
Graban M. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781498743259.
https://psnet.ahrq.gov/issue/lean-hospitals-improving-quality-patient-safety-and-employee-engagement-
third-edition
Lean methodology fo…
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psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
September 13, 2023 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use
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March 31…
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - A Stroke of Error
December 1, 2014
Barrett KM. A Stroke of Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/stroke-error
Case Objectives
State the key clinical factors to assess in a patient with suspected stroke.
Appreciate the relationship between elevated blood pressure and stroke in the acute sett…
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - SPOTLIGHT CASE
Falling Through the Crack (in the Bedrails)
Citation Text:
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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F…
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psnet.ahrq.gov/web-mm/poor-prognosis
March 15, 2016 - SPOTLIGHT CASE
Poor Prognosis
Citation Text:
Lamont EB. Poor Prognosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
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psnet.ahrq.gov/web-mm/departure-central-line-ritual
October 13, 2018 - Departure From Central Line Ritual
Citation Text:
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndN…
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room
Citation Text:
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac
Arrest
September 30, 2020
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
Disclosure of Relevant Financial Relationships: As a pr…
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - The Result Stopped Here
June 1, 2004
Astion ML. The Result Stopped Here. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/result-stopped-here
The Case
A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital
for continued wound care and intravenous (IV) antib…
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psnet.ahrq.gov/node/33614/psn-pdf
June 01, 2005 - Interpreting the Patient Safety Literature
June 1, 2005
Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
Perspective
Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…
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psnet.ahrq.gov/node/49461/psn-pdf
September 01, 2004 - Reaction to Dye
September 1, 2004
Cohan R. Reaction to Dye. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/reaction-dye
The Case
A patient was referred to urology after having several episodes of gross hematuria. The urologist thought
that the patient might have a renal mass and sent him to radiology for a…
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psnet.ahrq.gov/web-mm/wrong-channel
February 01, 2003 - The Wrong Channel
Citation Text:
Gosbee JW. The Wrong Channel
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…