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psnet.ahrq.gov/node/43122/psn-pdf
April 08, 2018 - Missed diagnosis of stroke in the emergency department:
a cross-sectional analysis of a large population-based
sample.
April 8, 2018
Newman-Toker DE, Moy E, Valente E, et al. Missed diagnosis of stroke in the emergency department: a
cross-sectional analysis of a large population-based sample. Diagnosis (Berl). 201…
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psnet.ahrq.gov/node/34704/psn-pdf
December 24, 2008 - Negligent care and malpractice claiming behavior in Utah
and Colorado.
December 24, 2008
Studdert DM, Thomas EJ, Burstin HR, et al. Negligent care and malpractice claiming behavior in Utah and
Colorado. Med Care. 2000;38(3):250-60.
https://psnet.ahrq.gov/issue/negligent-care-and-malpractice-claiming-behavior-utah-…
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psnet.ahrq.gov/issue/2-year-study-patient-safety-competency-assessment-29-clinical-laboratories
December 14, 2016 - Study
A 2-year study of patient safety competency assessment in 29 clinical laboratories.
Citation Text:
Reed RC, Kim S, Farquharson K, et al. A 2-Year Study of Patient Safety Competency Assessment in 29 Clinical Laboratories. Am J Clin Pathol. 2008;129(6). doi:10.1309/bm8jje1auca408tq…
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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - reversal of specific drugs such as opiates (check pupils), benzodiazepines, anticholinergics Send blood samples
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psnet.ahrq.gov/node/44305/psn-pdf
January 22, 2016 - National incidence of medication error in surgical patients
before and after Accreditation Council for Graduate
Medical Education duty-hour reform.
January 22, 2016
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients
Before and After Accreditation Council for Gra…
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psnet.ahrq.gov/issue/classifying-laboratory-incident-reports-identify-problems-jeopardize-patient-safety
May 13, 2020 - Study
Classifying laboratory incident reports to identify problems that jeopardize patient safety.
Citation Text:
Classifying laboratory incident reports to identify problems that jeopardize patient safety. Astion ML; Shojania KG; Hamill TR; Kim S; Ng VL.
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psnet.ahrq.gov/issue/quality-improvement-decrease-specimen-mislabeling-transfusion-medicine
September 11, 2024 - Study
Quality improvement to decrease specimen mislabeling in transfusion medicine.
Citation Text:
Quillen K, Murphy K. Quality improvement to decrease specimen mislabeling in transfusion medicine. Arch Pathol Lab Med. 2006;130(8):1196-1198.
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Google S…
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psnet.ahrq.gov/node/49530/psn-pdf
February 01, 2007 - Rapid Mis-St(r)ep
February 1, 2007
Kaplan EL. Rapid Mis-St(r)ep. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/rapid-mis-strep
The Case
A 5-year-old girl was brought to an urgent care center by her father with a 2-day history of fever to 103°F,
sore throat, and diffuse abdominal pain. There was no history…
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psnet.ahrq.gov/issue/identifying-cross-contaminants-and-specimen-mix-ups-surgical-pathology
July 22, 2020 - Review
Identifying cross contaminants and specimen mix-ups in surgical pathology.
Citation Text:
Hunt JL. Identifying cross contaminants and specimen mix-ups in surgical pathology. Adv Anat Pathol. 2008;15(4):211-7. doi:10.1097/PAP.0b013e31817bf596.
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…
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psnet.ahrq.gov/node/34010/psn-pdf
June 20, 2019 - ISMP Medication Safety Alert!® Nurse-Advise ERR.
June 20, 2019
Plymouth Meeting, PA: Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/ismp-medication-safety-alertr-nurse-advise-err
ISMP's newsletter was designed to specifically meet the needs of nurses who transcribe medication orders,
adminis…
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psnet.ahrq.gov/node/35241/psn-pdf
September 11, 2018 - Team communication in the operating room.
September 11, 2018
Davies JM. Team communication in the operating room. Acta Anaesthesiol Scand. 2005;49(7):898-901.
https://psnet.ahrq.gov/issue/team-communication-operating-room
The author presents sample cases from aviation to illustrate failures in team communication an…
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psnet.ahrq.gov/node/36253/psn-pdf
November 28, 2018 - Medication Reconciliation Handbook, 2nd edition.
November 28, 2018
American Society of Health-System Pharmacists, Joint Commission on Accreditation of Healthcare
Organizations. Oakbrook Terrace IL; Joint Commission Resources: 2009. ISBN 9781599403090.
https://psnet.ahrq.gov/issue/medication-reconciliation-handbook-…
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psnet.ahrq.gov/issue/patient-identification-error-among-prostate-needle-core-biopsy-specimens-are-we-ready-dna
November 16, 2022 - Study
Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out?
Citation Text:
Suba EJ, Pfeifer JD, Raab SS. Patient identification error among prostate needle core biopsy specimens--are we ready for a DNA time-out? J Urol. 2007;178(4 Pt …
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psnet.ahrq.gov/issue/transfusion-safety-nature-and-outcomes-errors-patient-registration
December 16, 2020 - Review
Transfusion safety: the nature and outcomes of errors in patient registration.
Citation Text:
Cohen R, Ning S, Yan MTS, et al. Transfusion Safety: The Nature and Outcomes of Errors in Patient Registration. Transfus Med Rev. 2019;33(2):78-83. doi:10.1016/j.tmrv.2018.11.004.
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psnet.ahrq.gov/issue/emergency-departments-are-higher-risk-locations-wrong-blood-tube-errors
November 17, 2021 - Study
Emergency departments are higher-risk locations for wrong blood in tube errors.
Citation Text:
Dunbar NM, Delaney M, Murphy MF, et al. Emergency departments are higher‐risk locations for wrong blood in tube errors. Transfusion (Paris). 2021;61(9):2601-2610. doi:10.1111/trf.16588.
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psnet.ahrq.gov/node/866567/psn-pdf
August 21, 2024 - A daily dose of communication to improve quality and
safety outcomes.
August 21, 2024
Halm MA. A daily dose of communication to improve quality and safety outcomes. Am J Crit Care.
2024;33(4):305-310. doi:10.4037/ajcc2024318.
https://psnet.ahrq.gov/issue/daily-dose-communication-improve-quality-and-safety-outcomes…
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psnet.ahrq.gov/issue/sins-omission-getting-too-little-medical-care-may-be-greatest-threat-patient-safety
March 06, 2005 - Study
Sins of omission. Getting too little medical care may be the greatest threat to patient safety.
Citation Text:
Hayward RA, Asch SM, Hogan MM, et al. Sins of omission: getting too little medical care may be the greatest threat to patient safety. J Gen Intern Med. 2005;20(8):686-91…
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - But every day, blood samples are switched between two patients.
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psnet.ahrq.gov/web-mm/rapid-mis-strep
February 01, 2004 - Rapid Mis-St(r)ep
Citation Text:
Kaplan EL. Rapid Mis-St(r)ep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/issue/using-ismp-medication-safety-self-assessment-improve-medication-use-processes
January 05, 2017 - Study
Using the ISMP Medication Safety Self-Assessment to improve medication use processes.
Citation Text:
Lesar TS, Mattis A, Anderson E, et al. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Jt Comm J Qual Saf. 2003;29(5):211-26.
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