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psnet.ahrq.gov/perspective/covid-19-and-built-environment
June 30, 2021 - water, or air transmission might be more environmental risk management programs with environmental sampling … to complement clinical surveillance and sampling for HAIs.
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psnet.ahrq.gov/web-mm/real-heartache
October 01, 2018 - artery disease (e.g., untreated hypertension, cigarette smoking, and premature family history), serial sampling
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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/web-mm/breakage-picc-line
June 21, 2023 - parenteral nutrition, anticancer agents, antibiotics, and blood products and also for the through-line blood sampling
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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/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/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - bronchoscopy not only provides visualization of the lower respiratory tract but can also allow for various sampling
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psnet.ahrq.gov/web-mm/unfamiliar-catheter
November 01, 2006 - Each lumen of a multi-lumen catheter is used for a different purpose, such as sampling, total parenteral
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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - yield false negatives for a variety of reasons, such as testing too soon after exposure or inadequate sampling
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - may be lower in community practice than in the manufacturer’s testing due to viral dynamics, sampling
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psnet.ahrq.gov/web-mm/hemolysis-holdup
July 03, 2016 - Hemolysis Holdup
Citation Text:
Lehman CM. Hemolysis Holdup. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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…
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psnet.ahrq.gov/issue/national-incidence-medication-error-surgical-patients-and-after-accreditation-council
September 23, 2020 - Study
National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform.
Citation Text:
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients Before and Afte…
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psnet.ahrq.gov/node/33591/psn-pdf
March 15, 2025 - Triggers and Trigger Tools
March 15, 2025
Triggers and Trigger Tools. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/triggers-and-trigger-tools
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
April 17, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Diagnostic Errors Case Studies
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Created By: Maria Mirica, PRIDE Group
…
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psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - completed, i.e., parenteral nutrition, or (iii) when the line is only being used for routine blood sampling
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psnet.ahrq.gov/issue/missed-diagnoses-acute-myocardial-infarction-emergency-department-variation-patient-and
April 08, 2018 - Study
Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics.
Citation Text:
Moy E, Barrett M, Coffey R, et al. Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and fa…
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psnet.ahrq.gov/node/47379/psn-pdf
November 14, 2018 - Analysis of medication therapy discontinuation orders in
new electronic prescriptions and opportunities for
implementing CancelRx.
November 14, 2018
Yang Y, Ward-Charlerie S, Kashyap N, et al. Analysis of medication therapy discontinuation orders in new
electronic prescriptions and opportunities for implementing C…
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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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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - Mother's Milk, but Whose Mother?
Citation Text:
Dougherty D. Mother's Milk, but Whose Mother?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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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-…