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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens
Citation Text:
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/849596/psn-pdf
May 31, 2023 - Patients admitted on weekends have higher in-hospital
mortality than those admitted on weekdays: analysis of
national inpatient sample.
May 31, 2023
Manadan A, Arora S, Whittier M, et al. Patients admitted on weekends have higher in-hospital mortality
than those admitted on weekdays: analysis of national inpatient…
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/node/34719/psn-pdf
December 23, 2008 - Learning from samples of one or fewer.
December 23, 2008
March JG, Sproull LS, Tamuz M. Org Sci.1991;2:1-13. (reprinted in: Qual Saf Health Care 2003;12:465-
472.)
https://psnet.ahrq.gov/issue/learning-samples-one-or-fewer
Organizations learn from experience. However, learning from rare events is challenging becau…
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psnet.ahrq.gov/issue/enhanced-detection-blood-bank-sample-collection-errors-centralized-patient-database
March 20, 2019 - Study
Enhanced detection of blood bank sample collection errors with a centralized patient database.
Citation Text:
MacIvor D, Triulzi DJ, Yazer MH. Enhanced detection of blood bank sample collection errors with a centralized patient database. Transfusion (Paris). 2009;49(1):40-3. doi:…
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psnet.ahrq.gov/node/43720/psn-pdf
November 26, 2014 - Hamilton father misdiagnosed with lung cancer demands
answers.
November 26, 2014
Carville O. The Star. November 14, 2014.
https://psnet.ahrq.gov/issue/hamilton-father-misdiagnosed-lung-cancer-demands-answers
This news article reports on a case involving a patient who was misdiagnosed with terminal cancer and
touc…
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psnet.ahrq.gov/node/45900/psn-pdf
June 07, 2017 - Blood bank specimen mislabeling: a College of American
Pathologists Q-Probes study of 41,333 blood bank
specimens in 30 institutions.
June 7, 2017
Novis DA, Lindholm PF, Ramsey G, et al. Blood Bank Specimen Mislabeling: A College of American
Pathologists Q-Probes Study of 41 333 Blood Bank Specimens in 30 Institut…
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Simplifying process—removing
unnecessary steps
Analyzer with direct tube sampling reduces the frequency
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psnet.ahrq.gov/issue/inappropriate-medication-national-sample-us-elderly-patients-receiving-home-health-care
September 09, 2020 - Study
Inappropriate medication in a national sample of US elderly patients receiving home health care.
Citation Text:
Bao Y, Shao H, Bishop TF, et al. Inappropriate medication in a national sample of US elderly patients receiving home health care. J Gen Intern Med. 2012;27(3):304-310. do…
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psnet.ahrq.gov/issue/prevalence-and-severity-patient-harm-sample-uk-hospitalised-children-detected-paediatric
February 15, 2023 - Study
Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool.
Citation Text:
Chapman SM, Fitzsimons J, Davey N, et al. Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatr…
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psnet.ahrq.gov/node/60044/psn-pdf
March 16, 2020 - Patient Safety in Medical, Nursing, and Other Clinical
Education
March 16, 2020
Howley LD, Hall KK, Fitall E. Patient Safety in Medical, Nursing, and Other Clinical Education . PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
Background
Despit…
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psnet.ahrq.gov/issue/relationships-between-pediatric-safety-indicators-across-national-sample-pediatric-hospitals
April 06, 2022 - Study
Relationships between pediatric safety indicators across a national sample of pediatric hospitals: dispelling the myth of the "safest" hospital.
Citation Text:
Milliren CE, Bailey G, Graham DA, et al. Relationships between pediatric safety indicators across a national sample of ped…
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psnet.ahrq.gov/issue/are-surgeons-and-anesthesiologists-lying-each-other-or-gaming-system-national-random-sample
June 29, 2022 - Study
Are surgeons and anesthesiologists lying to each other or gaming the system? A national random sample survey about "truth-telling practices" in the perioperative setting in the United States.
Citation Text:
Nurok M, Lee Y-Y, Ma Y, et al. Are surgeons and anesthesiologists lying to …
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psnet.ahrq.gov/issue/potential-preanalytical-and-analytical-vulnerabilities-laboratory-diagnosis-coronavirus
August 10, 2016 - Commentary
Potential preanalytical and analytical vulnerabilities in the laboratory diagnosis of coronavirus disease 2019 (COVID-19).
Citation Text:
Lippi G, Simundic A-M, Plebani M. Potential preanalytical and analytical vulnerabilities in the laboratory diagnosis of coronavirus disease…
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psnet.ahrq.gov/issue/transfusion-related-errors-and-associated-adverse-reactions-and-blood-product-wastage
September 23, 2020 - Study
Transfusion-related errors and associated adverse reactions and blood product wastage as reported to the National Healthcare Safety Network Hemovigilance Module, 2014-2022.
Citation Text:
Chavez Ortiz JL, Griffin I, Kazakova SV, et al. Transfusion‐related errors and associated adve…
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psnet.ahrq.gov/issue/comparison-quality-care-patients-veterans-health-administration-and-patients-national-sample
February 24, 2011 - Study
Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample.
Citation Text:
Asch SM, McGlynn EA, Hogan MM, et al. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sam…
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psnet.ahrq.gov/node/865336/psn-pdf
March 27, 2024 - Transfusion-related errors and associated adverse
reactions and blood product wastage as reported to the
National Healthcare Safety Network Hemovigilance
Module, 2014-2022.
March 27, 2024
Chavez Ortiz JL, Griffin I, Kazakova SV, et al. Transfusion?related errors and associated adverse reactions
and blood product …
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psnet.ahrq.gov/node/74077/psn-pdf
November 17, 2021 - Factors associated with wrong blood in tube errors: an
international case series - The BEST collaborative study.
November 17, 2021
Dunbar NM, Kaufman RM. Factors associated with wrong blood in tube errors: an international case series
– The BEST collaborative study. Transfusion (Paris). 2022;62(1):44-50. doi:10.111…
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psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based
April 08, 2018 - Study
Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample.
Citation Text:
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-b…
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psnet.ahrq.gov/node/43080/psn-pdf
March 26, 2014 - Hospital-based transfusion error tracking from 2005 to
2010: identifying the key errors threatening patient
transfusion safety.
March 26, 2014
Maskens C, Downie H, Wendt A, et al. Hospital-based transfusion error tracking from 2005 to 2010:
identifying the key errors threatening patient transfusion safety. Transfu…