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psnet.ahrq.gov/node/39489/psn-pdf
June 11, 2010 - What happens between visits? Adverse and potential
adverse events among a low-income, urban, ambulatory
population with diabetes.
June 11, 2010
Sarkar U, Handley MA, Gupta R, et al. What happens between visits? Adverse and potential adverse
events among a low-income, urban, ambulatory population with diabetes. Qua…
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psnet.ahrq.gov/node/45402/psn-pdf
November 01, 2017 - Potentially preventable 30-day hospital readmissions at a
children's hospital.
November 1, 2017
Toomey SL, Peltz A, Loren S, et al. Potentially Preventable 30-Day Hospital Readmissions at a Children's
Hospital. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4182.
https://psnet.ahrq.gov/issue/potentially-preventabl…
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psnet.ahrq.gov/node/46723/psn-pdf
April 12, 2019 - Diagnostic assessment of deep learning algorithms for
detection of lymph node metastases in women with
breast cancer.
April 12, 2019
Bejnordi BE, Veta M, van Diest PJ, et al. Diagnostic Assessment of Deep Learning Algorithms for Detection
of Lymph Node Metastases in Women With Breast Cancer. JAMA. 2017;318(22):219…
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psnet.ahrq.gov/node/46616/psn-pdf
July 02, 2019 - Medication-related clinical decision support alert
overrides in inpatients.
July 2, 2019
Nanji KC, Seger DL, Slight SP, et al. Medication-related clinical decision support alert overrides in
inpatients. J Am Med Inform Assoc. 2018;25(5):476-481. doi:10.1093/jamia/ocx115.
https://psnet.ahrq.gov/issue/medication-rel…
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psnet.ahrq.gov/node/40619/psn-pdf
October 06, 2016 - Sustaining and spreading the reduction of adverse drug
events in a multicenter collaborative.
October 6, 2016
Tham E, Calmes HM, Poppy A, et al. Sustaining and spreading the reduction of adverse drug events in a
multicenter collaborative. Pediatrics. 2011;128(2):e438-45. doi:10.1542/peds.2010-3772.
https://psnet.a…
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psnet.ahrq.gov/issue/dangerous-infections-are-more-likely-pediatric-intensive-care-units
December 18, 2019 - Newspaper/Magazine Article
Dangerous infections are more likely in pediatric intensive-care units.
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February 15, 2012
Consumer Re…
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psnet.ahrq.gov/node/60552/psn-pdf
June 03, 2020 - Personal protective equipment for preventing highly
infectious diseases due to exposure to contaminated
body fluids in healthcare staff.
June 3, 2020
Verbeek JH, Rajamaki B, Ijaz S, et al. Personal protective equipment for preventing highly infectious
diseases due to exposure to contaminated body fluids in healthc…
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psnet.ahrq.gov/node/45730/psn-pdf
December 14, 2016 - Identification of priorities for improvement of medication
safety in primary care: a PRIORITIZE study.
December 14, 2016
Car LT, Papachristou N, Gallagher J, et al. Identification of priorities for improvement of medication safety
in primary care: a PRIORITIZE study. BMC Fam Pract. 2016;17(1):160.
https://psnet.ah…
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psnet.ahrq.gov/node/43486/psn-pdf
September 01, 2016 - Indication alerts intercept drug name confusion errors
during computerized entry of medication orders.
September 1, 2016
Galanter W, Bryson M, Falck S, et al. Indication alerts intercept drug name confusion errors during
computerized entry of medication orders. PLoS One. 2014;9(7):e101977.
doi:10.1371/journal.pone…
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psnet.ahrq.gov/node/45425/psn-pdf
December 22, 2018 - Automated identification of antibiotic overdoses and
adverse drug events via analysis of prescribing alerts and
medication administration records.
December 22, 2018
Kirkendall ES, Kouril M, Dexheimer JW, et al. Automated identification of antibiotic overdoses and adverse
drug events via analysis of prescribing ale…
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psnet.ahrq.gov/node/845278/psn-pdf
March 01, 2023 - Association between opioid tapering and subsequent
health care use, medication adherence, and chronic
condition control.
March 1, 2023
Magnan EM, Tancredi DJ, Xing G, et al. Association between opioid tapering and subsequent health care
use, medication adherence, and chronic condition control. JAMA Netw Open. 2023…
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psnet.ahrq.gov/node/33592/psn-pdf
December 15, 2024 - Adverse Events, Near Misses, and Errors
December 15, 2024
Adverse Events, Near Misses, and Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current re…
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psnet.ahrq.gov/web-mm/discharge-against-medical-advice
July 01, 2017 - Discharge Against Medical Advice
Citation Text:
Hwang SW. Discharge Against Medical Advice. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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psnet.ahrq.gov/node/33693/psn-pdf
February 01, 2010 - The Role of Graduate Medical Education (GME) in
Improving Patient Safety
February 1, 2010
Baron RB, Vidyarthi A. The Role of Graduate Medical Education (GME) in Improving Patient Safety. PSNet
[internet]. 2010.
https://psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
Perspec…
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psnet.ahrq.gov/node/49582/psn-pdf
April 01, 2009 - Breakage of a PICC Line
April 1, 2009
Dimov V. Breakage of a PICC Line. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/breakage-picc-line
Case Objectives
Appreciate the incidence and consequences of PICC line breakage.
Understand the risk factors for PICC line breakage.
Understand the treatment options in…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.152_slideshow.ppt
June 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case June 2007
Beeline to Spine
Source and Credits
This presentation is based on June 2007
AHRQ WebM&M Spotlight Case
See full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Gerald W. Smetana, MD, Harvard Medical School, Beth Israel D…
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psnet.ahrq.gov/node/33717/psn-pdf
September 01, 2011 - Incident Reporting: More Attention to the Safety Action
Feedback Loop, Please
September 1, 2011
Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet
[internet]. 2011.
https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
…
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psnet.ahrq.gov/node/72618/psn-pdf
December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral
Changes Towards Medical Decisions that Improve Care
Value and Quality of Care
December 23, 2020
https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-
medical-decisions
Summary
Nudges are a change in the way choices ar…
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and
Umpires Have in Common?
February 1, 2007
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
Perspectiv…
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by:…