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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - Angle JF, Nemcek AA Jr, Cohen AM, et al; SIR Standards Division.
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - than all other patients who died to have received "care that departed from professionally recognized standards
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psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
September 01, 2017 - out personal gender bias, they should also recognize that gender bias is also present in diagnostic standards
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - mitigated through UC Davis Health, Office of Continuing Medical Education procedures to meet ACCME standards
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - Standards such as the Joint Commission National Patient Safety Goals provide a valuable framework for
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psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - Is there a way to get some best practice standards out there to help people optimize these things?
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psnet.ahrq.gov/node/49680/psn-pdf
March 01, 2013 - Strategies to promote these
behaviors include training in and standardization of pathologist–clinician
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - Around the Block
Citation Text:
Minichiello T. Around the Block. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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psnet.ahrq.gov/node/49630/psn-pdf
July 01, 2011 - Watch the Warfarin!
July 1, 2011
Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/watch-warfarin
Case Objectives
Understand best practices for safe discharge of patients on warfarin.
Describe recent advances in anticoagulation monitoring for ambulatory patients.
Discu…
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psnet.ahrq.gov/node/49869/psn-pdf
July 02, 2019 - Failure to Rescue the Mother
July 2, 2019
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/failure-rescue-mother
The Case
A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal
bleeding. An …
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psnet.ahrq.gov/node/865984/psn-pdf
May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain
with Elevated D-dimer.
May 29, 2024
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-
dimer. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d…
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psnet.ahrq.gov/node/49795/psn-pdf
June 01, 2017 - The Perils of Contrast Media
June 1, 2017
Sadat U, Solomon R. The Perils of Contrast Media. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/perils-contrast-media
Case Objectives
Recognize that contrast media are potentially nephrotoxic.
Identify key risk factors for the development of contrast-induced kidne…
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psnet.ahrq.gov/node/49621/psn-pdf
March 01, 2011 - Volume Too Low: In and Out
March 1, 2011
Miller MR. Volume Too Low: In and Out . PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/volume-too-low-and-out
Case Objectives
Appreciate that because of multiple factors, children are at high risk for medical errors.
Describe the importance of weight-based dosing of…
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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - The Case of Mistaken Intubation
June 1, 2016
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/case-mistaken-intubation
Case Objectives
Appreciate that most older adults and many younger chronically ill patients have discussed or
documented their preferences for l…
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psnet.ahrq.gov/node/867640/psn-pdf
February 26, 2025 - Patient safety of virtual primary care: a qualitative study
examining risks and mitigation strategies.
February 26, 2025
Lounsbury O, Li E, Lunova T, et al. Patient safety of virtual primary care: a qualitative study examining risks
and mitigation strategies. Health Policy Tech. 2025;14(1):100966. doi:10.1016/j.hlp…
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psnet.ahrq.gov/node/47225/psn-pdf
November 02, 2018 - Preventable adverse drug events among inpatients: a
systematic review.
November 2, 2018
Gates PJ, Meyerson SA, Baysari M, et al. Preventable Adverse Drug Events Among Inpatients: A
Systematic Review. Pediatrics. 2018;142(3):e20180805. doi:10.1542/peds.2018-0805.
https://psnet.ahrq.gov/issue/preventable-adverse-dru…
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psnet.ahrq.gov/node/39495/psn-pdf
September 20, 2011 - Safe Practices for Better Healthcare: 2010 Update.
September 20, 2011
Washington, DC: National Quality Forum; 2010.
https://psnet.ahrq.gov/issue/safe-practices-better-healthcare-2010-update
The National Quality Forum originally published the Safe Practices for Better Healthcare in 2003. These
practices are intende…
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psnet.ahrq.gov/node/36697/psn-pdf
February 03, 2011 - Deficits in communication and information transfer
between hospital-based and primary care physicians:
implications for patient safety and continuity of care.
February 3, 2011
Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between
hospital-based and primary care phys…
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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/42051/psn-pdf
October 08, 2013 - A closer look at associations between hospital leadership
walkrounds and patient safety climate and risk reduction:
a cross-sectional study.
October 8, 2013
Schwendimann R, Milne J, Frush K, et al. A closer look at associations between hospital leadership
walkrounds and patient safety climate and risk reduction: a…