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psnet.ahrq.gov/node/867805/psn-pdf
February 26, 2025 - In Conversation with David W. Bates about Are We Safer
Today?
February 26, 2025
Bates DW, Lee M, Mossburg SE. In Conversation with David W. Bates about Are We Safer Today? PSNet
[internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
Editor’s note: David W. Bates, …
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psnet.ahrq.gov/node/73113/psn-pdf
April 07, 2021 - Analysis of results from event investigations in industrial
and patient safety contexts.
April 7, 2021
Harms-Ringdahl L. Analysis of results from event investigations in industrial and patient safety contexts.
Safety. 2021;7(1):19. doi:10.3390/safety7010019.
https://psnet.ahrq.gov/issue/analysis-results-event-inve…
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psnet.ahrq.gov/node/838135/psn-pdf
January 01, 2023 - The fallacy of a single diagnosis.
September 21, 2022
Redelmeier DA, Shafir E. The fallacy of a single diagnosis. Med Decis Making. 2023;43(2):183-190.
doi:10.1177/0272989x221121343.
https://psnet.ahrq.gov/issue/fallacy-single-diagnosis
Premature closure occurs when clinicians accept a diagnosis before it has been…
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psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - The nurse suggested a stat x-ray be done in
light of the recent surgery. … signout.(1,2,11,12)
Many strategies, proven successful in non-health care industries (13), have been suggested
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psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - The nurse suggested a stat x-ray be done in light of the recent surgery. … signout.( 1,2,11,12 ) Many strategies, proven successful in non-health care industries ( 13 ), have been suggested
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psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - misplaced small-bore feeding tubes reported to the Pennsylvania Patient Safety Authority in 2011-2013 suggested … [Free full text ] Training suggested when changing brands of enteral feeding tubes.
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psnet.ahrq.gov/node/74097/psn-pdf
November 24, 2021 - Inattentional blindness in anesthesiology: a gorilla is
worth one thousand words.
November 24, 2021
De Cassai A, Negro S, Geraldini F, et al. Inattentional blindness in anesthesiology: a gorilla is worth one
thousand words. PLoS One. 2021;16(9):e0257508. doi:10.1371/journal.pone.0257508.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/issue/spike-people-dying-home-suggests-coronavirus-deaths-houston-may-be-higher-reported
January 30, 2019 - Newspaper/Magazine Article
A spike in people dying at home suggests coronavirus deaths in Houston may be higher than reported.
Citation Text:
Ornstein C, Hixenbaugh M. A spike in people dying at home suggests coronavirus deaths in Houston may be higher than reported. ProPublica and NBC N…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
June 01, 2004 - He suggested that the boy still receive the Hepatitis B vaccine.
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - They suggested that rather than attempting to create a just
culture that balances a systems approach
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psnet.ahrq.gov/node/74863/psn-pdf
February 23, 2022 - Factors associated with missed nursing care and nurse-
assessed quality of care during the COVID-19 pandemic.
February 23, 2022
Labrague LJ, Santos JAA, Fronda DC. Factors associated with missed nursing care and nurse?assessed
quality of care during the COVID?19 pandemic. J Nurs Manag. 2022;30(1):62-70. doi:10.1111…
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psnet.ahrq.gov/node/60325/psn-pdf
May 13, 2020 - Impacts of operational failures on primary care
physicians' work: a critical interpretive synthesis of the
literature.
May 13, 2020
Sinnott C, Georgiadis A, Park J, et al. Impacts of operational failures on primary care physicians' work: a
critical interpretive synthesis of the literature. Ann Fam Med. 2020;18(2):…
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psnet.ahrq.gov/node/842772/psn-pdf
January 18, 2023 - Short- and long-term effects of an electronic medication
management system on paediatric prescribing errors.
January 18, 2023
Westbrook JI, Li L, Raban MZ, et al. Short- and long-term effects of an electronic medication management
system on paediatric prescribing errors. NPJ Digit Med. 2022;5(1):179. doi:10.1038/s4…
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psnet.ahrq.gov/issue/patient-safety-incident-reporting-and-learning-guidelines-implemented-health-care
January 08, 2025 - Review
Patient safety incident reporting and learning guidelines implemented by health care professionals in specialized care units: scoping review.
Citation Text:
Gqaleni TM, Mkhize SW, Chironda G. Patient safety incident reporting and learning guidelines implemented by health care prof…
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psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
February 26, 2025 - Going back to what you suggested: that the current energy or motivation for hospital administrations … Some data recently came out that suggested as much, which is a bit concerning.
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psnet.ahrq.gov/perspective/equity-patient-safety
September 24, 2024 - The students suggested additional cultural competency training. … These commentators have suggested that the future utility of AI is complex, but at minimum, as regulation
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psnet.ahrq.gov/node/47014/psn-pdf
July 02, 2019 - Multisource evaluation of surgeon behavior is associated
with malpractice claims.
July 2, 2019
Lagoo J, Berry WR, Miller K, et al. Multisource Evaluation of Surgeon Behavior Is Associated With
Malpractice Claims. Ann Surg. 2019;270(1):84-90. doi:10.1097/SLA.0000000000002742.
https://psnet.ahrq.gov/issue/multisourc…
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psnet.ahrq.gov/node/48173/psn-pdf
August 28, 2019 - Does learning from mistakes have to be painful? Analysis
of 5 years' experience from the Leeds radiology
educational cases meetings identifies common repetitive
reporting errors and suggests acknowledging and
celebrating excellence (ACE) as a more positive way of
teaching the same lessons.
August 28, 2019
Koo A,…
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psnet.ahrq.gov/node/866846/psn-pdf
September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 24, 2024
Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/zero…
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psnet.ahrq.gov/issue/does-learning-mistakes-have-be-painful-analysis-5-years-experience-leeds-radiology
April 05, 2013 - Study
Does learning from mistakes have to be painful? Analysis of 5 years' experience from the Leeds radiology educational cases meetings identifies common repetitive reporting errors and suggests acknowledging and celebrating excellence (ACE) as a more positive way of teaching the same lessons.
…