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psnet.ahrq.gov/node/837813/psn-pdf
January 21, 2021 - Recognizing Excellence in Diagnosis.
January 21, 2021
The Leapfrog Group.
https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis
Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise
to be successful. This collaborative initiative will initially dev…
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psnet.ahrq.gov/node/33603/psn-pdf
September 15, 2024 - Surgical Site Infections
September 15, 2024
Surgical Site Infections. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/surgical-site-infections
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety …
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psnet.ahrq.gov/node/49429/psn-pdf
January 01, 2004 - Ruptured Heterotopic Pregnancy
January 1, 2004
Cedars MI. Ruptured Heterotopic Pregnancy. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy
The Case
A 43-year-old woman, gravida 3 para 2, presented at 16 weeks' gestational age with abdominal pain. Her
current pregnancy was the r…
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psnet.ahrq.gov/node/841306/psn-pdf
December 14, 2022 - Resilient Healthcare and the Safety-I and Safety-II
Frameworks
December 14, 2022
Deutsch ES, Van CM, Mossburg SE. Resilient Healthcare and the Safety-I and Safety-II Frameworks.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
Resilient healthca…
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psnet.ahrq.gov/node/49764/psn-pdf
June 01, 2016 - Communication With Consultants
June 1, 2016
Cohn SL. Communication With Consultants. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/communication-consultants
The Case
A 30-year-old pregnant woman presented to the emergency department (ED) with nausea, headaches, and
fevers. Her laboratory studies were nota…
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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/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
July 01, 2003 - PowerPoint Presentation
Spotlight Case July 2003
Code Status Confusion
webmm.ahrq.gov
Source and Credits
This presentation is based on the July 2003
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Bernard Lo, MD, Univers…
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psnet.ahrq.gov/node/49539/psn-pdf
June 01, 2007 - Informed or Misled?
June 1, 2007
White SM. Informed or Misled? . PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/informed-or-misled
The Case
A 50-year-old man arrived at the hospital for an elective total knee replacement. Based on preoperative
discussions, the patient expected to receive spinal anesthesia.…
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psnet.ahrq.gov/node/72616/psn-pdf
December 22, 2020 - Adverse Events in Dentistry
December 22, 2020
Kalenderian E, Walji MF, Fitall E, et al. Adverse Events in Dentistry. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/adverse-events-dentistry
Introduction
Similar to many other healthcare settings, dentistry carries with it inherent patient safety risks. D…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
December 01, 2009 - Spotlight Case [MONTH] 2003
Spotlight Case
Standard Deviations
Source and Credits
This presentation is based on the December 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: James E. Sabin, MD
Harvard Medical School; Harvard Pilgrim Heal…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Bad Writing, Wrong Medication
*
*
Source and Credits
This presentation is based on the April 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Beth Devine, PharmD, MBA, PhD
University of Washingto…
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psnet.ahrq.gov/node/49652/psn-pdf
May 01, 2012 - Double Dose at Transfer
May 1, 2012
Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/double-dose-transfer
The Case
A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department
(ED) for left lower extremity pain, swelling, and erythe…
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psnet.ahrq.gov/node/33657/psn-pdf
September 01, 2007 - Rediscovering the Power of the Surgical M&M
Conference: The M+M Matrix
September 1, 2007
Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
Perspective
There is a slumbe…
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psnet.ahrq.gov/issue/recognizing-our-biases-understanding-evidence-and-responding-equitably-application
April 05, 2023 - Commentary
Recognizing our biases, understanding the evidence, and responding equitably: application of the socioecological model to reduce racial disparities in the NICU.
Citation Text:
McCarty DB. Recognizing our biases, understanding the evidence, and responding equitably: application…
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psnet.ahrq.gov/node/45021/psn-pdf
April 06, 2016 - Scandal as a sentinel event—recognizing hidden
cost–quality trade-offs.
April 6, 2016
Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med.
2016;374(11):1001-3. doi:10.1056/NEJMp1502629.
https://psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-t…
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psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - could be avoided with interoperability, inadequate availability of patient information is a widely recognized … Inadequate availability of patient information is a widely recognized problem that results in patient
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psnet.ahrq.gov/web-mm/picture-speaks-1000-words
July 16, 2015 - Tragically, the limitation of the workaround was only recognized when a single patient presented with … Take-Home Points Workarounds should be recognized as limited, and perhaps dangerous, processes people
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psnet.ahrq.gov/node/33695/psn-pdf
April 01, 2010 - technical information to consumers
in a way that is easily understood ("evaluable") is slowly being recognized … time-
efficient consensus process, which will help NQF to achieve the goal of becoming the nationally recognized
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - The ward team recognized these clinical changes, yet they had no knowledge of the prior
radiograph findings … First, had the general surgery resident on call formally reviewed the case,
the team may have recognized
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psnet.ahrq.gov/issue/society-critical-care-medicine-guidelines-recognizing-and-responding-clinical-deterioration
April 24, 2018 - Organizational Policy/Guidelines
Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023.
Citation Text:
Honarmand K, Wax RS, Penoyer D, et al. Society of Critical Care Medicine Guidelines on Recognizing and Responding to…