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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - SPOTLIGHT CASE
CE/MOC
New
Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery
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Christian Bohring…
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psnet.ahrq.gov/issue/gift-failure-new-approaches-analyzing-and-learning-events-and-near-misses
March 06, 2005 - Special or Theme Issue
The Gift of Failure: New Approaches to Analyzing and Learning from Events and Near-Misses.
Citation Text:
Fahlbruch B, Carroll JS, eds. Safety Sci. 2011;49(1):1-106
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psnet.ahrq.gov/issue/using-external-errors-signal-clear-and-present-danger
August 06, 2008 - Newspaper/Magazine Article
Using external errors to signal a clear and present danger.
Citation Text:
ISMP Medication Safety Alert! Acute Care Edition. November 6, 2008;13:1-2.
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psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
March 29, 2023 - Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.
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Christian Bohringer, MD
| March 15, 2023
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psnet.ahrq.gov/issue/action-research-simulation-team-communication-and-bringing-tacit-voice-society-simulation
October 03, 2018 - Study
Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare.
Citation Text:
Forsythe L. Action research, simulation, team communication, and bringing the tacit into voice society for simulation in healthcare. Simul Heal…
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psnet.ahrq.gov/issue/can-we-use-incident-reports-detect-hospital-adverse-events
March 06, 2005 - Study
Can we use incident reports to detect hospital adverse events?
Citation Text:
Blais R; Bruno D; Bartlett G; Tamblyn R.
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psnet.ahrq.gov/issue/reporting-and-using-near-miss-events-improve-patient-safety-diverse-primary-care-practices
June 22, 2011 - Study
Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes.
Citation Text:
Crane S, Sloane PD, Elder NC, et al. Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Pr…
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psnet.ahrq.gov/issue/close-calls-patient-safety-should-we-be-paying-closer-attention
February 12, 2014 - Commentary
Close calls in patient safety: should we be paying closer attention?
Citation Text:
Wu AW, Marks CM. Close calls in patient safety: should we be paying closer attention? CMAJ. 2013;185(13):1119-20. doi:10.1503/cmaj.130014.
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DOI Google Schol…
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psnet.ahrq.gov/issue/patient-safety-objective-structured-clinical-examination
September 12, 2007 - Study
A patient safety objective structured clinical examination.
Citation Text:
Singh R, Singh A, Fish R, et al. A patient safety objective structured clinical examination. J Patient Saf. 2009;5(2):55-60. doi:10.1097/PTS.0b013e31819d65c2.
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psnet.ahrq.gov/issue/prevention-potential-errors-resuscitation-medications-orders-means-computerised-physician
January 25, 2006 - Study
Prevention of potential errors in resuscitation medications orders by means of a computerised physician order entry in paediatric critical care.
Citation Text:
Vardi A; Efrati O; Levin I; Matok I; Rubinstein M; Paret G; Barzilay Z.
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psnet.ahrq.gov/issue/crowdsourcing-diagnosis-patients-undiagnosed-illnesses-evaluation-crowdmed
March 06, 2013 - Study
Crowdsourcing diagnosis for patients with undiagnosed illnesses: an evaluation of CrowdMed.
Citation Text:
Meyer AND, Longhurst CA, Singh H. Crowdsourcing Diagnosis for Patients With Undiagnosed Illnesses: An Evaluation of CrowdMed. J Med Internet Res. 2016;18(1):e12. doi:10.2196/j…
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psnet.ahrq.gov/issue/preventing-overdiagnosis-how-stop-harming-healthy
May 18, 2016 - Commentary
Preventing overdiagnosis: how to stop harming the healthy.
Citation Text:
Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ. 2012;344:e3502. Published 2012 May 28. doi:10.1136/bmj.e3502
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psnet.ahrq.gov/issue/avoidability-hospital-deaths-and-association-hospital-wide-mortality-ratios-retrospective
November 12, 2014 - Study
Classic
Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis.
Citation Text:
Hogan H, Zipfel R, Neuburger J, et al. Avoidability of hospital deaths and association wit…
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psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
September 26, 2023 - In Conversation With… Thomas J. Nasca, MD, MACP
April 1, 2016
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Editor's note: Dr. Nasca is Chief Executive Officer of the Accredita…
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psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
December 23, 2020 - SPOTLIGHT CASE
Recurrent Hypoglycemia: A Care Transition Failure?
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Ted Eytan, MD, MS, MPH | October 1, 2008
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Case …
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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2016 - Annual Perspective
Computerized Provider Order Entry and Patient Safety
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
October 01, 2008 - Spotlight Case July 2008
Spotlight Case
Recurrent Hypoglycemia:
A Care Transition Failure?
*
*
Source and Credits
This presentation is based on the October 2008 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Ted Eytan, MD, MS, MPH
Editor, …
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psnet.ahrq.gov/issue/patients-willingness-and-ability-participate-actively-reduction-clinical-errors-systematic
February 24, 2021 - Review
Patients' willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review.
Citation Text:
DOHERTY CAROLE, STAVROPOULOU CHARITINI. Patients' willingness and ability to participate actively in the reduction of clinical errors: a …
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psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
March 29, 2023 - An Incomplete Anesthesia History Leads to Adverse Outcomes
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Christian Bohringer, MD | July 8, 2022
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The Cases
Case 1: A 64-yea…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - Spotlight Case July 2008
Spotlight Case
Delirium or Dementia?
Source and Credits
This presentation is based on the May 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: James L. Rudolph, MD, SM
Editor, AHRQ WebM&M: Robert Wachter, MD
Sp…