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psnet.ahrq.gov/issue/risk-management-extreme-honesty-may-be-best-policy
January 04, 2017 - Study
Classic
Risk management: extreme honesty may be the best policy.
Citation Text:
Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131(12):963-967.
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psnet.ahrq.gov/issue/differential-diagnosis-checklists-reduce-diagnostic-error-differentially-randomised
September 23, 2020 - Study
Differential diagnosis checklists reduce diagnostic error differentially: a randomised experiment.
Citation Text:
Kämmer JE, Schauber SK, Hautz SC, et al. Differential diagnosis checklists reduce diagnostic error differentially: a randomised experiment. Med Educ. 2021;55(10):1172-1…
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psnet.ahrq.gov/web-mm/premature-extubation
May 25, 2011 - If there is no cuff leak, it suggests that laryngeal edema or another type of laryngeal injury has reduced
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psnet.ahrq.gov/node/39610/psn-pdf
April 16, 2018 - Safeguarding the storage of drug products.
April 16, 2018
PA-PSRS Patient Saf Advis. 2010;7(2):46-51.
https://psnet.ahrq.gov/issue/safeguarding-storage-drug-products
This piece characterizes medication storage methods that contribute to adverse drug events and provides
suggestions for improvement.
https://psnet.a…
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psnet.ahrq.gov/node/36071/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-6
This monthly selection of medication error reports provides examples of nimodipine administration
mishaps, a lithium overdose, and suggested adopted drug names for review.
https://ps…
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - Although the root causes of diagnostic errors have not been fully elucidated, research in the field suggests
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psnet.ahrq.gov/issue/aging-stigma-and-health-us-adults-over-65-what-do-we-know
December 23, 2020 - Review
Aging stigma and the health of US adults over 65: what do we know?
Citation Text:
Allen J, Sikora N. Aging stigma and the health of US adults over 65: what do we know? Clin Interv Aging. 2023;18:2093-2116. doi:10.2147/cia.s396833.
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psnet.ahrq.gov/issue/identifying-and-analyzing-diagnostic-paths-new-approach-studying-diagnostic-practices
July 17, 2019 - Commentary
Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices.
Citation Text:
Rao G, Epner P, Bauer V, et al. Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices. Diagnosis (Berl). 2017;4(2):67-72. doi:10.…
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psnet.ahrq.gov/issue/impact-2011-accreditation-council-graduate-medical-education-duty-hour-reform-quality-and
April 05, 2013 - Study
The impact of the 2011 Accreditation Council for Graduate Medical Education duty hour reform on quality and safety in trauma care.
Citation Text:
Marwaha JS, Drolet BC, Maddox SS, et al. The Impact of the 2011 Accreditation Council for Graduate Medical Education Duty Hour Reform on…
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psnet.ahrq.gov/issue/risk-factors-retained-instruments-and-sponges-after-surgery
February 17, 2011 - Study
Classic
Risk factors for retained instruments and sponges after surgery.
Citation Text:
Gawande AA, Studdert DM, Orav J, et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348(3):229-35.
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psnet.ahrq.gov/issue/transparency-when-things-go-wrong-physician-attitudes-about-reporting-medical-errors-patients
April 13, 2011 - Study
Transparency when things go wrong: physician attitudes about reporting medical errors to patients, peers, and institutions.
Citation Text:
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.
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psnet.ahrq.gov/issue/changing-and-sustaining-medical-students-knowledge-skills-and-attitudes-about-patient-safety
December 19, 2012 - Study
Changing and sustaining medical students' knowledge, skills, and attitudes about patient safety and medical fallibility.
Citation Text:
Madigosky WS, Headrick LA, Nelson K, et al. Changing and sustaining medical students' knowledge, skills, and attitudes about patient safety and …
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psnet.ahrq.gov/issue/technological-distractions-part-1-and-part-2
April 24, 2018 - Review
Technological distractions—part 1 and part 2.
Citation Text:
Kane-Gill SL, O'Connor MF, Rothschild JM, et al. Technologic Distractions (Part 1): Summary of Approaches to Manage Alert Quantity With Intent to Reduce Alert Fatigue and Suggestions for Alert Fatigue Metrics. Crit Care …
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psnet.ahrq.gov/issue/inattentional-blindness-anesthesiology-gorilla-worth-one-thousand-words
June 01, 2022 - Study
Inattentional blindness in anesthesiology: a gorilla is worth one thousand words.
Citation Text:
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.02575…
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psnet.ahrq.gov/issue/taking-pulse-health-care-systems-experiences-patients-health-problems-six-countries
December 23, 2012 - Multi-use Website
Classic
Taking the pulse of health care systems: experiences of patients with health problems in six countries.
Citation Text:
Schoen C, Osborn R, Huynh PT, et al. Taking The Pulse Of Health Care Systems: Experiences Of Patients With Health P…
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psnet.ahrq.gov/issue/physician-knowledge-attitudes-and-behavior-related-reporting-adverse-drug-events
September 23, 2020 - Study
Classic
Physician knowledge, attitudes, and behavior related to reporting adverse drug events.
Citation Text:
Rogers AS, Israel E, Smith CR, et al. Physician Knowledge, Attitudes, and Behavior Related to Reporting Adverse Drug Events. Arch Intern Med. 201…
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psnet.ahrq.gov/node/35601/psn-pdf
June 21, 2010 - Is employee discipline the solution for patient safety?
June 21, 2010
Mace KA. Is employee discipline the solution for patient safety? Nurs Manag. 2005;36(12):57-59.
https://psnet.ahrq.gov/issue/employee-discipline-solution-patient-safety
The author provides suggestions on how to support a blame-free culture and en…
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psnet.ahrq.gov/node/39848/psn-pdf
April 16, 2018 - Diagnostic error in acute care.
April 16, 2018
PA-PSRS Patient Saf Advis. September 2010;7:76-86.
https://psnet.ahrq.gov/issue/diagnostic-error-acute-care
Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for
physicians and patients to prevent such events.
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psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
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psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…