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psnet.ahrq.gov/node/848358/psn-pdf
May 03, 2023 - Identifying electronic health record contributions to
diagnostic error in ambulatory settings through legal
claims analysis.
May 3, 2023
Krevat S, Samuel S, Boxley C, et al. Identifying electronic health record contributions to diagnostic error in
ambulatory settings through legal claims analysis. JAMA Netw Open. …
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psnet.ahrq.gov/node/50836/psn-pdf
January 29, 2020 - Developing a cancer-specific trigger tool to identify
treatment-related adverse events using administrative
data.
January 29, 2020
Weingart SN, Nelson J, Koethe B, et al. Developing a cancer?specific trigger tool to identify treatment?
related adverse events using administrative data. Cancer Med. 2020;9(4):1462-14…
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - and institutional administration may better address the impact of medical errors on caregivers at all stages
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psnet.ahrq.gov/node/39124/psn-pdf
February 18, 2011 - Adverse drug event rates in six community hospitals and
the potential impact of computerized physician order
entry for prevention.
February 18, 2011
Hug BL, Witkowski DJ, Sox CM, et al. Adverse Drug Event Rates in Six Community Hospitals and the
Potential Impact of Computerized Physician Order Entry for Prevention…
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psnet.ahrq.gov/node/44922/psn-pdf
March 01, 2017 - Mobilising a team for the WHO Surgical Safety Checklist:
a qualitative video study.
March 1, 2017
Korkiakangas T. Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study. BMJ
Qual Saf. 2017;26(3):177-188. doi:10.1136/bmjqs-2015-004887.
https://psnet.ahrq.gov/issue/mobilising-team-who-sur…
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psnet.ahrq.gov/issue/patient-safety-tools-improving-safety-point-care-0
September 08, 2021 - Multi-use Website
Patient Safety Tools: Improving Safety at the Point of Care.
Save
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November 14, 2011
Produced in conjunction with it…
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psnet.ahrq.gov/node/850161/psn-pdf
June 07, 2023 - Analysis of the nature and contributory factors of
medication safety incidents following hospital discharge
using National Reporting and Learning System (NRLS)
data from England and Wales: a multi-method study.
June 7, 2023
Alqenae FA, Steinke DT, Carson-Stevens A, et al. Analysis of the nature and contributory fa…
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psnet.ahrq.gov/node/45965/psn-pdf
April 19, 2017 - Measuring harm and informing quality improvement in the
Welsh NHS: the longitudinal Welsh national adverse
events study.
April 19, 2017
Mayor S, Baines E, Vincent CA, et al. Measuring Harm And Informing Quality Improvement In The Welsh
Nhs: The Longitudinal Welsh National Adverse Events Study. Southampton, UK: NIH…
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psnet.ahrq.gov/node/44393/psn-pdf
August 12, 2015 - FDA Drug Safety Communication: FDA warns about
prescribing and dispensing errors resulting from brand
name confusion with antidepressant Brintellix
(vortioxetine) and antiplatelet Brilinta (ticagrelor).
August 12, 2015
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; July 30, 2015.
https…
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psnet.ahrq.gov/node/37992/psn-pdf
August 20, 2008 - Medication errors reported by US family physicians and
their office staff.
August 20, 2008
Kuo GM, Phillips RL, Graham D, et al. Medication errors reported by US family physicians and their office
staff. Quality and Safety in Health Care. 2008;17(4). doi:10.1136/qshc.2007.024869.
https://psnet.ahrq.gov/issue/medic…
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psnet.ahrq.gov/node/34795/psn-pdf
December 23, 2008 - Preventable adverse drug events in hospitalized patients:
a comparative study of intensive care and general care
units.
December 23, 2008
Cullen DJ, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients. Crit
Care Med. 1997;25(8):1289-1297. doi:10.1097/00003246-199708000-00014.
ht…
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psnet.ahrq.gov/node/612828/psn-pdf
February 23, 2022 - Delayed Diagnosis of Kidney Transplant Complications
February 23, 2022
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
Objectives
Recognition, early evaluation, and management of kidney …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
October 01, 2010 - Spotlight Case July 2008
Spotlight Case October 2010
Dangerous Dialysis
*
*
Source and Credits
This presentation is based on the October 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…
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psnet.ahrq.gov/node/38758/psn-pdf
July 08, 2009 - An international review of patient safety measures in
radiotherapy practice.
July 8, 2009
Shafiq J, Barton M, Noble DJ, et al. An international review of patient safety measures in radiotherapy
practice. Radiother Oncol. 2009;92(1):15-21. doi:10.1016/j.radonc.2009.03.007.
https://psnet.ahrq.gov/issue/international…
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psnet.ahrq.gov/node/47582/psn-pdf
December 12, 2018 - Success in hospital-acquired pressure ulcer prevention: a
tale in two data sets.
December 12, 2018
Smith S, Snyder A, McMahon LF, et al. Success In Hospital-Acquired Pressure Ulcer Prevention: A Tale In
Two Data Sets. Health Aff (Millwood). 2018;37(11):1787-1796. doi:10.1377/hlthaff.2018.0712.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/40807/psn-pdf
September 01, 2016 - Prevalence of medication administration errors in two
medical units with automated prescription and
dispensing.
September 1, 2016
Rodriguez-Gonzalez CG, Herranz-Alonso A, Martin-Barbero ML, et al. Prevalence of medication
administration errors in two medical units with automated prescription and dispensing. J Am M…
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psnet.ahrq.gov/node/60825/psn-pdf
August 19, 2020 - Effect of delays in the 2-week-wait cancer referral
pathway during the COVID-19 pandemic on cancer
survival in the UK: a modelling study.
August 19, 2020
Sud A, Torr B, Jones ME, et al. Effect of delays in the 2-week-wait cancer referral pathway during the
COVID-19 pandemic on cancer survival in the UK: a modellin…
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psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
April 24, 2024 - Extravasation may be categorized into 4 stages according to the severity of the injury, as described
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psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - Dangerous Dialysis
October 1, 2010
Holley JL. Dangerous Dialysis . PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/dangerous-dialysis
Case Objectives
List common errors that occur in dialysis units.
Describe steps that can be taken by dialysis units to prevent these common errors.
Describe the role of the …
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psnet.ahrq.gov/node/50393/psn-pdf
September 01, 2019 - From the early stages of the
patient safety field, beginning with the 1999 To Err Is Human report, there