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psnet.ahrq.gov/node/46656/psn-pdf
February 07, 2018 - Autopsy interrogation of emergency medicine dispute
cases: how often are clinical diagnoses incorrect?
February 7, 2018
Liu D, Gan R, Zhang W, et al. Autopsy interrogation of emergency medicine dispute cases: how often are
clinical diagnoses incorrect? J Clin Pathol. 2018;71(1):67-71. doi:10.1136/jclinpath-2017-204…
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psnet.ahrq.gov/node/46505/psn-pdf
August 20, 2018 - Americans' Experiences With Medical Errors and Views
on Patient Safety.
August 20, 2018
Chicago, IL: NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute; 2017.
https://psnet.ahrq.gov/issue/americans-experiences-medical-errors-and-views-patient-safety
Patient perspectives have been shown to identi…
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psnet.ahrq.gov/node/47671/psn-pdf
January 01, 2019 - Racial, ethnic, and socioeconomic disparities in patient
safety events for hospitalized children.
December 19, 2018
Stockwell DC, Landrigan CP, Toomey SL, et al. Racial, Ethnic, and Socioeconomic Disparities in Patient
Safety Events for Hospitalized Children. Hosp Pediatr. 2019;9(1):1-5. doi:10.1542/hpeds.2018-0131…
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psnet.ahrq.gov/node/47602/psn-pdf
January 27, 2019 - Association of nurse workload with missed nursing care
in the neonatal intensive care unit.
January 27, 2019
Tubbs-Cooley HL, Mara CA, Carle AC, et al. Association of Nurse Workload With Missed Nursing Care in
the Neonatal Intensive Care Unit. JAMA Pediatr. 2019;173(1):44-51.
doi:10.1001/jamapediatrics.2018.3619.
…
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psnet.ahrq.gov/node/49784/psn-pdf
February 01, 2017 - Safeguarding Diagnostic Testing at the Point of Care
February 1, 2017
Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
The Case
A 23-year-old woman presented to the family medicine clinic for…
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psnet.ahrq.gov/node/33665/psn-pdf
March 01, 2008 - Creation of a Medical Procedure Service to Improve
Patient Safety
March 1, 2008
Smith CC, CHuang G. Creation of a Medical Procedure Service to Improve Patient Safety. PSNet [internet].
2008.
https://psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
Perspective
Introduction and …
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psnet.ahrq.gov/node/46201/psn-pdf
September 27, 2017 - Risk factors for patient-reported errors during cancer
follow-up: results from a national survey in Denmark.
September 27, 2017
Christiansen AH, Lipczak H, Knudsen JL, et al. Risk factors for patient-reported errors during cancer follow-
up: Results from a national survey in Denmark. Cancer Epidemiol. 2017;49:38-45…
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psnet.ahrq.gov/node/35324/psn-pdf
February 03, 2011 - Neurobehavioral performance of residents after heavy
night call vs after alcohol ingestion.
February 3, 2011
Arnedt JT, Owens J, Crouch M, et al. Neurobehavioral Performance of Residents After Heavy Night Call vs
After Alcohol Ingestion. JAMA. 2005;294(9). doi:10.1001/jama.294.9.1025.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/46391/psn-pdf
February 08, 2018 - Nature of blame in patient safety incident reports: mixed
methods analysis of a national database.
February 8, 2018
Cooper J, Edwards A, Williams H, et al. Nature of Blame in Patient Safety Incident Reports: Mixed Methods
Analysis of a National Database. Ann Fam Med. 2017;15(5):455-461. doi:10.1370/afm.2123.
https…
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psnet.ahrq.gov/node/34734/psn-pdf
March 28, 2005 - The Definition of Quality and Approaches to Its
Assessment. Vol 1. Explorations in Quality Assessment
and Monitoring.
March 28, 2005
Donahedian A. Ann Arbor, MI; Health Administration Press: 1980. ISBN: 9780914904489.
https://psnet.ahrq.gov/issue/definition-quality-and-approaches-its-assessment-vol-1-explorations-…
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psnet.ahrq.gov/node/41301/psn-pdf
April 18, 2012 - Voluntary electronic reporting of laboratory errors: an
analysis of 37,532 laboratory event reports from 30 health
care organizations.
April 18, 2012
Snydman LK, Harubin B, Kumar S, et al. Voluntary electronic reporting of laboratory errors: an analysis of
37,532 laboratory event reports from 30 health care organi…
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psnet.ahrq.gov/node/39512/psn-pdf
June 11, 2010 - An intervention to decrease patient identification band
errors in a children's hospital.
June 11, 2010
Hain PD, Joers B, Rush M, et al. An intervention to decrease patient identification band errors in a
children's hospital. Qual Saf Health Care. 2010;19(3):244-7. doi:10.1136/qshc.2008.030288.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/47082/psn-pdf
July 02, 2019 - Effect of systematic physician cross-checking on
reducing adverse events in the emergency department:
the CHARMED cluster randomized trial.
July 2, 2019
Freund Y, Goulet H, Leblanc J, et al. Effect of Systematic Physician Cross-checking on Reducing Adverse
Events in the Emergency Department: The CHARMED Cluster Ra…
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psnet.ahrq.gov/node/44601/psn-pdf
February 23, 2018 - Emergency department visits for adverse events related
to dietary supplements.
February 23, 2018
Geller AI, Shehab N, Weidle NJ, et al. Emergency Department Visits for Adverse Events Related to Dietary
Supplements. N Engl J Med. 2015;373(16):1531-40. doi:10.1056/NEJMsa1504267.
https://psnet.ahrq.gov/issue/emergenc…
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psnet.ahrq.gov/node/38428/psn-pdf
February 18, 2009 - Adverse Events in Hospitals: Care Study of Incidence
Among Medicare Beneficiaries in Two Selected Counties.
February 18, 2009
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector
General; December 2008. Report No. OEI-06-08-00220.
https://psnet.ahrq.gov/issue/adverse-eve…
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psnet.ahrq.gov/node/35927/psn-pdf
February 17, 2011 - Claims, errors, and compensation payments in medical
malpractice litigation.
February 17, 2011
Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical
malpractice litigation. N Engl J Med. 2006;354(19):2024-33.
https://psnet.ahrq.gov/issue/claims-errors-and-compensation-payme…
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psnet.ahrq.gov/node/35611/psn-pdf
June 23, 2010 - Error or "act of God"? A study of patients' and operating
room team members' perceptions of error definition,
reporting, and disclosure.
June 23, 2010
Espin S, Levinson W, Regehr G, et al. Error or "act of God"? A study of patients' and operating room team
members' perceptions of error definition, reporting, and d…
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psnet.ahrq.gov/node/44178/psn-pdf
July 03, 2016 - A trigger tool to detect harm in pediatric inpatient
settings.
July 3, 2016
Stockwell DC, Bisarya H, Classen D, et al. A trigger tool to detect harm in pediatric inpatient settings.
Pediatrics. 2015;135(6):1036-42. doi:10.1542/peds.2014-2152.
https://psnet.ahrq.gov/issue/trigger-tool-detect-harm-pediatric-inpatien…
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psnet.ahrq.gov/node/33737/psn-pdf
September 01, 2012 - Preparing for Health Reform: The Federal Government
and the Nursing Workforce
September 1, 2012
Buerhaus P. Preparing for Health Reform: The Federal Government and the Nursing Workforce. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
Per…
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psnet.ahrq.gov/node/47267/psn-pdf
September 05, 2018 - The national cost of adverse drug events resulting from
inappropriate medication-related alert overrides in the
United States.
September 5, 2018
Slight SP, Seger DL, Franz C, et al. The national cost of adverse drug events resulting from inappropriate
medication-related alert overrides in the United States. J Am M…