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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - Psychiatric consultation services routinely conduct both types of
evaluations
• Timing of patient’s request
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psnet.ahrq.gov/issue/comparison-clinical-diagnoses-and-autopsy-findings-six-year-retrospective-study
March 27, 2024 - Study
Comparison of clinical diagnoses and autopsy findings: six-year retrospective study.
Citation Text:
Marshall HS, Milikowski C. Comparison of clinical diagnoses and autopsy findings: six-year retrospective study. Arch Pathol Lab Med. 2017;141(9):1262-1266. doi:10.5858/arpa.2016-0488…
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psnet.ahrq.gov/issue/physician-communication-when-prescribing-new-medications
December 16, 2009 - Study
Physician communication when prescribing new medications.
Citation Text:
Tarn DM, Heritage J, Paterniti DA, et al. Physician communication when prescribing new medications. Arch Intern Med. 2006;166(17):1855-1862.
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Google Scholar PubMed BibTeX E…
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psnet.ahrq.gov/issue/medicolegal-aspect-error-pathology-search-jury-verdicts-and-settlements
February 04, 2016 - Review
The medicolegal aspect of error in pathology: a search of jury verdicts and settlements.
Citation Text:
Kornstein MJ, Byrne SP. The medicolegal aspect of error in pathology: a search of jury verdicts and settlements. Arch Pathol Lab Med. 2007;131(4):615-618.
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…
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psnet.ahrq.gov/issue/pharmacist-and-prescriber-responsibilities-avoiding-prescription-drug-misuse
October 13, 2018 - Commentary
Pharmacist and prescriber responsibilities for avoiding prescription drug misuse.
Citation Text:
Pharmacist and prescriber responsibilities for avoiding prescription drug misuse. AMA J Ethics. 2021;23(6):E471-479. doi:10.1001/amajethics.2021.471.
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psnet.ahrq.gov/node/49541/psn-pdf
August 21, 2007 - Mark My Tooth
August 21, 2007
Smith RA. Mark My Tooth. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/mark-my-tooth
The Case
A 45-year-old healthy man was scheduled to have two teeth extracted for progressive dental caries. The
patient underwent the extractions, awoke from the anesthesia, and then realized…
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psnet.ahrq.gov/node/49509/psn-pdf
April 01, 2006 - Insert Omission
April 1, 2006
Darney P. Insert Omission. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/insert-omission
The Case
A multiparous woman presented to the gynecology clinic requesting intrauterine contraceptive (IUC)
placement (Figure). She was appropriately counseled on the risks and benefits o…
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psnet.ahrq.gov/node/49421/psn-pdf
October 01, 2003 - Urine a Tough Position
October 1, 2003
Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/urine-tough-position
The Case
A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although
she did not want to have a baby at that time, she sta…
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psnet.ahrq.gov/issue/hastened-death-due-disease-burden-and-distress-has-not-received-timely-quality-palliative
July 22, 2020 - Commentary
Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error.
Citation Text:
Gallagher R, Passmore MJ, Baldwin C. Hastened death due to disease burden and distress that has not received timely, quality palliative ca…
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psnet.ahrq.gov/issue/reduction-opioid-prescribing-through-evidence-based-prescribing-guidelines
January 27, 2019 - Study
Reduction in opioid prescribing through evidence-based prescribing guidelines.
Citation Text:
Howard R, Waljee JF, Brummett CM, et al. Reduction in Opioid Prescribing Through Evidence-Based Prescribing Guidelines. JAMA Surg. 2018;153(3):285-287. doi:10.1001/jamasurg.2017.4436.
Co…
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psnet.ahrq.gov/issue/implementing-rise-second-victim-support-programme-johns-hopkins-hospital-case-study
March 03, 2019 - Study
Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study.
Citation Text:
Edrees HH, Connors C, Paine LA, et al. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. BMJ Open. 2016;6(9):e011708. d…
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psnet.ahrq.gov/issue/new-electronic-health-records-unknown-queue-caused-multiple-events-patient-harm
October 12, 2022 - Book/Report
The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.
Citation Text:
The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm. Washington, DC: VA Office of the Inspector General; July 14 2022. Report No. 22-011…
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psnet.ahrq.gov/issue/discrepancies-between-clinical-diagnoses-and-autopsy-findings-critically-ill-children
January 12, 2022 - Study
Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study.
Citation Text:
Carlotti APCP, Bachette LG, Carmona F, et al. Discrepancies Between Clinical Diagnoses and Autopsy Findings in Critically Ill Children: A Prospective Study.…
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psnet.ahrq.gov/issue/patient-access-electronic-health-records-during-hospitalization
October 19, 2022 - Study
Patient access to electronic health records during hospitalization.
Citation Text:
Pell JM, Mancuso M, Limon S, et al. Patient access to electronic health records during hospitalization. JAMA Intern Med. 2015;175(5):856-858. doi:10.1001/jamainternmed.2015.121.
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F…
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psnet.ahrq.gov/issue/need-closed-loop-systems-management-abnormal-test-results
May 20, 2019 - Study
The need for closed-loop systems for management of abnormal test results.
Citation Text:
Zuccotti G, Samal L, Maloney FL, et al. The Need for Closed-Loop Systems for Management of Abnormal Test Results. Ann Intern Med. 2018;168(11):820-821. doi:10.7326/M17-2425.
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…
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psnet.ahrq.gov/issue/use-novel-modified-fishbone-diagram-analyze-diagnostic-errors
February 13, 2019 - Commentary
Use of a novel, modified fishbone diagram to analyze diagnostic errors.
Citation Text:
Reilly JB, Myers JS, Salvador D, et al. Use of a novel, modified fishbone diagram to analyze diagnostic errors. Diagnosis (Berl). 2014;1(2):167-171. doi:10.1515/dx-2013-0040.
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psnet.ahrq.gov/issue/situ-simulation-based-team-training-and-its-significance-transfer-learning-clinical-practice
June 14, 2023 - Study
In situ simulation-based team training and its significance for transfer of learning to clinical practice--a qualitative focus group interview study of anaesthesia personnel.
Citation Text:
Finstad AS, Aase I, Bjørshol CA, et al. In situ simulation-based team training and its signi…
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psnet.ahrq.gov/issue/liability-reform-should-make-patients-safer-avoidable-classes-events-are-key-improvement
July 26, 2023 - Commentary
Liability reform should make patients safer: "Avoidable classes of events" are a key improvement.
Citation Text:
Bovbjerg RR, Tancredi LR. Liability reform should make patients safer: "avoidable classes of events" are a key improvement. J Law Med Ethics. 2005;33(3):478-500. …
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psnet.ahrq.gov/issue/identification-inpatient-dnr-status-safety-hazard-begging-standardization
January 19, 2012 - Study
Identification of inpatient DNR status: a safety hazard begging for standardization.
Citation Text:
Sehgal NL, Wachter RM. Identification of inpatient DNR status: A safety hazard begging for standardization. J Hosp Med. 2007;2(6):366-371. doi:10.1002/jhm.283.
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…
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psnet.ahrq.gov/issue/role-talking-and-keeping-silent-physician-coping-medical-error-qualitative-study
February 16, 2011 - Study
The role of talking (and keeping silent) in physician coping with medical error: a qualitative study.
Citation Text:
May NB, Plews-Ogan M. The role of talking (and keeping silent) in physician coping with medical error: a qualitative study. Patient Educ Couns. 2012;88(3):449-54. …