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psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
November 01, 2016 - a POLST form, and 45% stated the orders changed treatment decisions.( 12 ) Another study in Oregon suggested … encouraging studies about the impact of POLST forms in Oregon, a more recent study of 230 EMTs in New York suggested
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psnet.ahrq.gov/node/857060/psn-pdf
November 27, 2023 - A recent literature review suggested
that it can be difficult to bridge the gap between theory and practice
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psnet.ahrq.gov/node/49650/psn-pdf
March 01, 2012 - Unfortunately, a recent study suggested that Mohs surgeons incorrectly identify
biopsy sites 5.9% of
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psnet.ahrq.gov/node/47467/psn-pdf
January 21, 2019 - Application of electronic trigger tools to identify targets
for improving diagnostic safety.
January 21, 2019
Murphy DR, Meyer AN, Sittig DF, et al. Application of electronic trigger tools to identify targets for improving
diagnostic safety. BMJ Qual Saf. 2019;28(2):151-159. doi:10.1136/bmjqs-2018-008086.
https://…
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psnet.ahrq.gov/node/47579/psn-pdf
December 12, 2018 - A prescription for enhancing electronic prescribing
safety.
December 12, 2018
Schiff G, Mirica MM, Dhavle AA, et al. A Prescription For Enhancing Electronic Prescribing Safety. Health
Aff (Millwood). 2018;37(11):1877-1883. doi:10.1377/hlthaff.2018.0725.
https://psnet.ahrq.gov/issue/prescription-enhancing-electroni…
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psnet.ahrq.gov/node/46904/psn-pdf
August 20, 2018 - Effect of a pediatric early warning system on all-cause
mortality in hospitalized pediatric patients.
August 20, 2018
Parshuram CS, Dryden-Palmer K, Farrell C, et al. Effect of a Pediatric Early Warning System on All-Cause
Mortality in Hospitalized Pediatric Patients: The EPOCH Randomized Clinical Trial. JAMA.
201…
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psnet.ahrq.gov/node/44302/psn-pdf
August 04, 2015 - The Global Comparators project: international
comparison of 30-day in-hospital mortality by day of the
week.
August 4, 2015
Ruiz M, Bottle A, Aylin PP. The Global Comparators project: international comparison of 30-day in-hospital
mortality by day of the week. BMJ Qual Saf. 2015;24(8):492-504. doi:10.1136/bmjqs-20…
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psnet.ahrq.gov/node/40600/psn-pdf
September 09, 2011 - To make or buy patient safety solutions: a resource
dependence and transaction cost economics perspective.
September 9, 2011
Fareed N, Mick SS. To make or buy patient safety solutions: a resource dependence and transaction cost
economics perspective. Health Care Manage Rev. 2011;36(4):288-298.
doi:10.1097/HMR.0b01…
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psnet.ahrq.gov/issue/patient-safety-indicators-england-hospital-administrative-data-case-control-analysis-and
June 15, 2011 - Study
Patient safety indicators for England from hospital administrative data: case-control analysis and comparison with US data.
Citation Text:
Raleigh VS, Cooper J, Bremner SA, et al. Patient safety indicators for England from hospital administrative data: case-control analysis and c…
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psnet.ahrq.gov/node/49449/psn-pdf
June 01, 2004 - Lethal Vertigo
June 1, 2004
Furman JM. Lethal Vertigo. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-vertigo
The Case
A 64-year-old woman, with no prior medical history, complained of sudden onset of severe vertigo and
vomiting, without headache. Her initial blood pressure in the emergency departme…
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psnet.ahrq.gov/node/45314/psn-pdf
September 01, 2018 - The "Seven Pillars" response to patient safety incidents:
effects on medical liability processes and outcomes.
September 1, 2018
Lambert BL, Centomani NM, Smith KM, et al. The "Seven Pillars" Response to Patient Safety Incidents:
Effects on Medical Liability Processes and Outcomes. Health Serv Res. 2016;51(suppl 3)…
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psnet.ahrq.gov/node/43969/psn-pdf
November 17, 2017 - Transparency when things go wrong: physician attitudes
about reporting medical errors to patients, peers, and
institutions.
November 17, 2017
Bell SK, White AA, Yi JC, et al. Transparency When Things Go Wrong. J Patient Saf. 2015;13(4):243-248.
doi:10.1097/pts.0000000000000153.
https://psnet.ahrq.gov/issue/transp…
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psnet.ahrq.gov/node/45118/psn-pdf
January 23, 2017 - Cluster randomized trial to evaluate the impact of team
training on surgical outcomes.
January 23, 2017
Duclos A, Peix JL, Piriou V, et al. Cluster randomized trial to evaluate the impact of team training on
surgical outcomes. Br J Surg. 2016;103(13):1804-1814. doi:10.1002/bjs.10295.
https://psnet.ahrq.gov/issue/c…
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psnet.ahrq.gov/node/45744/psn-pdf
December 19, 2017 - Complication rates, hospital size, and bias in the CMS
Hospital-Acquired Condition Reduction Program.
December 19, 2017
Koenig L, Soltoff SA, Demiralp B, et al. Complication Rates, Hospital Size, and Bias in the CMS Hospital-
Acquired Condition Reduction Program. Am J Med Qual. 2017;32(6):611-616.
doi:10.1177/1062…
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psnet.ahrq.gov/node/841468/psn-pdf
December 14, 2022 - They suggested the use of appropriately
sized bite blocks (to prevent the teeth from closing on the
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psnet.ahrq.gov/node/43928/psn-pdf
April 08, 2018 - Missed diagnoses of acute myocardial infarction in the
emergency department: variation by patient and facility
characteristics.
April 8, 2018
Moy E, Barrett M, Coffey R, et al. Missed diagnoses of acute myocardial infarction in the emergency
department: variation by patient and facility characteristics. Diagnosis …
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psnet.ahrq.gov/node/49488/psn-pdf
August 21, 2005 - https://psnet.ahrq.gov//#references
Beyond drastically improving the user interface, a recent article suggested
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psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - For example, some experts have suggested
labeling at the proximal and distal end of tubes and color
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psnet.ahrq.gov/node/33794/psn-pdf
November 01, 2015 - Harvard Library to try to look up information about patient safety and found nothing, the librarian suggested
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - cause analysis of a fatal medication error identified multiple contributing factors and more than 15 suggested