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psnet.ahrq.gov/issue/surgical-black-box-could-reduce-errors
June 04, 2014 - April 30, 2014
Organ donor's surgery death sparks questions.
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psnet.ahrq.gov/issue/buying-wrong-medicine-overseas
August 22, 2007 - June 22, 2009
To protect against drug errors, ask questions.
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psnet.ahrq.gov/node/33756/psn-pdf
October 01, 2013 - repetitive protocols are necessary and
have enabled CT to answer a more diverse range of clinical questions … The absence of good data for most
clinical questions has led to overimaging for many years, and that's … Unfortunately, the evidence that can guide imaging is in short supply and, for
most clinical questions
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psnet.ahrq.gov/node/49656/psn-pdf
June 01, 2012 - Some
questions to address in the agreement include:
Who is responsible for identifying patients to … The
surgeon and medicine physician should determine whom nurses would call when they have specific
questions
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psnet.ahrq.gov/perspective/relationships-between-physician-professional-satisfaction-and-patient-safety
September 29, 2017 - qualitative component of our study demonstrated, to talk with frontline physicians at length and ask tough questions … When the answers to these questions suggest that problems are present in patient care delivery, the best
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psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
March 01, 2013 - as we can, but at the same time, we have to recognize that we may never know the answer to certain questions … I will discuss the results in relation to four key questions.
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psnet.ahrq.gov/node/49622/psn-pdf
March 01, 2011 - We could ask several questions about their
assumptions and actions: Why did they not take responsibility … Because of this, these are the better questions to ask: Why did anyone have to assume anything in the … The real questions are: does the design increase the risk of a safety event?
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psnet.ahrq.gov/node/42508/psn-pdf
December 18, 2017 - Watson: Beyond Jeopardy!
December 18, 2017
Ferrucci D, Levas A, Bagchi S, et al. Watson: Beyond Jeopardy!. Artif Intell. 2012;199-200.
doi:10.1016/j.artint.2012.06.009.
https://psnet.ahrq.gov/issue/watson-beyond-jeopardy
This commentary describes how question answering systems can augment evidence-based decision
…
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - Wyatt, again, showed how three questions arise in almost every clinical encounterand sadly, two out … Yes, we might use a set of digital questionnaires to help us ask all the right questions, but finally … If a digital resource answers questions more quickly in their workflow, they're much more interested
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psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - Or did he raise
ambiguous questions like, "Has anyone seen the catheter tip?"
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psnet.ahrq.gov/node/35922/psn-pdf
July 26, 2010 - Nursing 2006 Patient-safety survey report.
July 26, 2010
Manno M, Hogan P, Heberlein V, et al. Nursing 2006. Patient-safety survey report. Nursing (Brux).
2006;36(5):54-64.
https://psnet.ahrq.gov/issue/nursing-2006-patient-safety-survey-report
The investigators analyzed the results of a 2005 survey of approximatel…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
November 01, 2003 - Spotlight Case [MONTH] 2003
Spotlight Case November 2003
The Missing Suction Tip
Source and Credits
This presentation is based on the Nov. 2003
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Eric J. Thomas, MD,…
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …
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psnet.ahrq.gov/node/36359/psn-pdf
October 26, 2010 - How might acknowledging a medical error promote
patient safety?
October 26, 2010
Malaty W, Crane S. How might acknowledging a medical error promote patient safety? J Fam Pract.
2006;55(9):775-80.
https://psnet.ahrq.gov/issue/how-might-acknowledging-medical-error-promote-patient-safety
The authors present a case o…
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psnet.ahrq.gov/node/33863/psn-pdf
August 01, 2018 - research directions for you and your team over the next 5 or 10 years, what are the
most important questions
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psnet.ahrq.gov/issue/boys-life-lost-sepsis-thousands-are-saved-his-wake
November 07, 2012 - February 27, 2019
In treating sepsis, questions about timing and mandates.
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psnet.ahrq.gov/issue/how-dangerous-day-hospital-model-adverse-events-and-length-stay-medical-inpatients
February 09, 2012 - Study
Classic
How dangerous is a day in hospital?: A model of adverse events and length of stay for medical inpatients.
Citation Text:
Hauck K, Zhao X. How dangerous is a day in hospital? A model of adverse events and length of stay for medical inpatients. Med…
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psnet.ahrq.gov/node/33750/psn-pdf
May 01, 2013 - The bottom line is I don't know the answers to these questions and neither does anyone else.
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psnet.ahrq.gov/node/35780/psn-pdf
July 20, 2010 - Paramedic intubation errors: isolated events or
symptoms of larger problems?
July 20, 2010
Wang HE, Lave J, Sirio CA, et al. Paramedic intubation errors: isolated events or symptoms of larger
problems? Health Aff (Millwood). 2006;25(2):501-9.
https://psnet.ahrq.gov/issue/paramedic-intubation-errors-isolated-events…
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psnet.ahrq.gov/node/43435/psn-pdf
August 06, 2014 - Trail of medical missteps in a Peace Corps death.
August 6, 2014
Stolberg SG.
https://psnet.ahrq.gov/issue/trail-medical-missteps-peace-corps-death
Raising concerns about health care provided by the Peace Corps, this newspaper article outlines an
investigation into failures, such as cognitive biases and poor judgm…