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psnet.ahrq.gov/node/863762/psn-pdf
March 14, 2024 - Diagnostic Excellence: a Patient Safety Awareness Week
Webinar.
March 6, 2024
Institute for Healthcare Improvement. March 14, 2024.
https://psnet.ahrq.gov/issue/diagnostic-excellence-patient-safety-awareness-week-webinar
Diagnostic safety is core to care without harm. This webinar aligned with the 2024 Patient Saf…
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - The original study found
that gaps in data represented the biggest challenge to compliance because clinical
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psnet.ahrq.gov/node/49480/psn-pdf
May 01, 2005 - Diagnosing Diagnostic Mistakes
May 1, 2005
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
Learning Objectives
Understand the biases that may contribute to overcalling medical errors
Describe the impact of conside…
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psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH
November 1, 2010
In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…
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psnet.ahrq.gov/issue/investigating-association-alerts-national-mortality-surveillance-system-subsequent-hospital
October 20, 2021 - Study
Investigating the association of alerts from a national mortality surveillance system with subsequent hospital mortality in England: an interrupted time series analysis.
Citation Text:
Cecil E, Bottle A, Esmail A, et al. Investigating the association of alerts from a national morta…
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psnet.ahrq.gov/issue/impact-traditional-and-smart-pump-infusion-technology-nurse-medication-administration
May 18, 2022 - Study
The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.
Citation Text:
Trbovich PL, Pinkney S, Cafazzo JA, et al. The impact of traditional and smart pump infusion technology on nurse medication ad…
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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - The Commentary At first glance, the problem represented by this case seems trivially obvious.
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psnet.ahrq.gov/node/49687/psn-pdf
August 21, 2013 - The committee's judgment was that this represented a diagnostic error and that this was
a preventable
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psnet.ahrq.gov/web-mm/caution-interrupted
October 01, 2016 - successful completion of a previous step, or when the point at which to resume the task is not clearly represented
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psnet.ahrq.gov/web-mm/liposuction-gone-awry
July 01, 2003 - Such hematomas represented nearly one-third of reported sequelae.
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psnet.ahrq.gov/node/33682/psn-pdf
April 01, 2009 - physician data are published on a rolling 3-year time period to make sure that adequate
volumes are represented
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psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - Bourgeois, OD, MD and Glen Xiong, MD
8
BACKGROUND
9
Background (1)
• This unfortunate case likely represented
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psnet.ahrq.gov/node/60035/psn-pdf
September 22, 2023 - SOPS Medical Office Database.
March 11, 2020
Agency for Healthcare Research and Quality (AHRQ). March 2020.
https://psnet.ahrq.gov/issue/sops-medical-office-database
This website provides a report and data repository representing medical offices that administered the
AHRQ Surveys on Patient Safety Culture™ (SOPS®)…
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - represents a measure taken to enhance patient safety; with each “slice,” things can still go wrong,
represented
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psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-improves-maternal-and
September 23, 2024 - Project Nurture Engages Pregnant People with Substance Use Disorder, Improves Maternal and Infant Outcomes.
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March 11, 2021
Innovation
…
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psnet.ahrq.gov/node/50719/psn-pdf
December 04, 2019 - A lot happens when you report a hazard or error to
ISMP—there’s no “black hole” here!
December 4, 2019
ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019
https://psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here
The reporting and analysis of incidents i…
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psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - Triggers and Trigger Tools
Citation Text:
Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/node/47621/psn-pdf
May 11, 2019 - 2018 update on pediatric medical overuse: a review.
May 11, 2019
Coon ER, Quinonez RA, Morgan DJ, et al. 2018 Update on Pediatric Medical Overuse: A Review. JAMA
Pediatr. 2019;173(4):379-384. doi:10.1001/jamapediatrics.2018.5550.
https://psnet.ahrq.gov/issue/2018-update-pediatric-medical-overuse-review
Overuse of …
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psnet.ahrq.gov/node/843091/psn-pdf
January 25, 2023 - Anesthesia outside of the OR: cause for patient safety
concerns?
January 25, 2023
DePeau-Wilson M. MedPage Today. January 13, 2023.
https://psnet.ahrq.gov/issue/anesthesia-outside-or-cause-patient-safety-concerns
The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicia…
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psnet.ahrq.gov/node/73572/psn-pdf
August 04, 2021 - Center for Innovations in Quality, Effectiveness and
Safety. IQuESt!
August 4, 2021
Houston, TX: Baylor College of Medicine.
https://psnet.ahrq.gov/issue/center-innovations-quality-effectiveness-and-safety-iquest
This Center represents a partnership with the Veterans Affairs Health Services Research & Develo…