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psnet.ahrq.gov/node/35892/psn-pdf
July 23, 2010 - Medical errors: should you apologize?
July 23, 2010
Weiss GG. Medical errors. Should you apologize? Medical economics. 2006;83(8):50-4.
https://psnet.ahrq.gov/issue/medical-errors-should-you-apologize
This article discusses disclosure of adverse events from various perspectives and provides suggestions on
apologiz…
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psnet.ahrq.gov/node/36574/psn-pdf
March 09, 2009 - Studying organisational cultures and their effects on
safety.
March 9, 2009
Hopkins A. Studying organisational cultures and their effects on safety. Saf Sci. 2006;44(10).
doi:10.1016/j.ssci.2006.05.005.
https://psnet.ahrq.gov/issue/studying-organisational-cultures-and-their-effects-safety
The author shares exampl…
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psnet.ahrq.gov/node/35506/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-1
This monthly selection of medication error reports provides examples of drug misadministration, confusion
with drug names, and administration of chemotherapy to the wrong patient, plu…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - Although the root causes of diagnostic errors have not been fully elucidated, research in the field suggests
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psnet.ahrq.gov/node/36627/psn-pdf
February 07, 2007 - Doctors say patients who lie may put their health at risk.
February 7, 2007
Johnson CK.
https://psnet.ahrq.gov/issue/doctors-say-patients-who-lie-may-put-their-health-risk
This article describes how and why patients lie to their physicians and shares suggestions
for communication improvement to encourage patient f…
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psnet.ahrq.gov/node/35487/psn-pdf
September 12, 2016 - Safety improvements urged for MRI facilities.
September 12, 2016
Mitka M. Safety improvements urged for MRI facilities. JAMA. 2005;294(17):2145-8.
https://psnet.ahrq.gov/issue/safety-improvements-urged-mri-facilities
This news story from JAMA summarizes a teleconference on magnetic resonance imaging safety
and sha…
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psnet.ahrq.gov/node/37354/psn-pdf
November 21, 2007 - Fires during surgeries a bigger risk than thought.
November 21, 2007
Kowalczyk L. Boston Globe. November 7, 2007
https://psnet.ahrq.gov/issue/fires-during-surgeries-bigger-risk-thought
This article reports data suggesting that the number of surgical fires that occur annually may be higher than
health care official…
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psnet.ahrq.gov/node/36546/psn-pdf
January 10, 2011 - A systems approach to patient-centered care.
January 10, 2011
Bergeson SC, Dean JD. A systems approach to patient-centered care. JAMA. 2006;296(23):2848-51.
https://psnet.ahrq.gov/issue/systems-approach-patient-centered-care
The authors suggest system-level changes to help health care professionals ensure that they…
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psnet.ahrq.gov/node/36347/psn-pdf
March 18, 2010 - Skin tears: the clinical challenge.
March 18, 2010
PA PSRS Patient Saf Advis 2006 Sep;3(3):1,5-10.
https://psnet.ahrq.gov/issue/skin-tears-clinical-challenge
This article discusses the Pennsylvania Patient Safety Reporting System (PA-PSRS) reports of skin tears
and provides suggestions to help keep patients safe f…
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psnet.ahrq.gov/node/36171/psn-pdf
September 29, 2010 - Quality and safety in the intensive care unit.
September 29, 2010
Stockwell DC, Slonim A. Quality and safety in the intensive care unit. J Intensive Care Med.
2006;21(4):199-210.
https://psnet.ahrq.gov/issue/quality-and-safety-intensive-care-unit
The authors provide background on patient safety in intensive care u…
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psnet.ahrq.gov/node/36995/psn-pdf
September 14, 2011 - Adverse drug events in the elderly.
September 14, 2011
Cresswell KM, Fernando B, McKinstry B, et al. Adverse drug events in the elderly. Br Med Bull. 2007;83(1).
doi:10.1093/bmb/ldm016.
https://psnet.ahrq.gov/issue/adverse-drug-events-elderly
The authors discuss drug-related adverse events in the elderly and provi…
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psnet.ahrq.gov/node/35107/psn-pdf
April 06, 2011 - Fewer but better auditory alarms will improve patient
safety.
April 6, 2011
Edworthy J. Fewer but better auditory alarms will improve patient safety. Qual Saf Health Care.
2005;14(3):212-215. doi:10.1136/qshc.2004.013052.
https://psnet.ahrq.gov/issue/fewer-better-auditory-alarms-will-improve-patient-safety
The au…
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psnet.ahrq.gov/node/37009/psn-pdf
March 18, 2010 - Doing the "right" things to correct wrong-site surgery.
March 18, 2010
Patient Safety Advisory
https://psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results
of other studies, and provides suggesti…
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psnet.ahrq.gov/node/35973/psn-pdf
August 13, 2010 - Follow-up tips for a safe, efficient practice.
August 13, 2010
Weiss GG. Follow-up tips for a safe, efficient practice. Medical economics. 2006;83(10):47-9.
https://psnet.ahrq.gov/issue/follow-tips-safe-efficient-practice
This article provides suggestions for physicians to ensure reliable follow-up on test results,…
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psnet.ahrq.gov/node/36169/psn-pdf
August 09, 2006 - Disruptive clinician behavior: a persistent threat to patient
safety.
August 9, 2006
Porto G; Lauve R. Patient Safety Quality Healthcare. July / August 2006.
https://psnet.ahrq.gov/issue/disruptive-clinician-behavior-persistent-threat-patient-safety
The authors describe disruptive clinician behavior, contributing …
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psnet.ahrq.gov/node/38286/psn-pdf
June 06, 2018 - Actively caring for safety: overcoming bystander apathy.
June 6, 2018
ISMP Medication Safety Alert! Acute Care Edition. November 20, 2008:13:1-3.
https://psnet.ahrq.gov/issue/actively-caring-safety-overcoming-bystander-apathy
This article provides suggestions to help individuals counteract the tendency for group in…
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psnet.ahrq.gov/node/40375/psn-pdf
August 08, 2014 - Coordination Between Emergency and Primary Care
Physicians.
August 8, 2014
Carrier E, Yee T, Holtzwart RA. Washington, DC: National Institute for Health Care Reform; 2011. NIHCR
Research Brief No. 3.
https://psnet.ahrq.gov/issue/coordination-between-emergency-and-primary-care-physicians
This report analyzes commu…
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psnet.ahrq.gov/node/35055/psn-pdf
November 04, 2015 - Using pharmacogenetics to improve drug safety and
efficacy.
November 4, 2015
Haga SB, Burke W. Using pharmacogenetics to improve drug safety and efficacy. JAMA.
2004;291(23):2869-71.
https://psnet.ahrq.gov/issue/using-pharmacogenetics-improve-drug-safety-and-efficacy
The authors outline reasons why pharmacogeneti…
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psnet.ahrq.gov/node/36592/psn-pdf
May 08, 2018 - Anticoagulant safety takes center stage in 2007.
May 8, 2018
ISMP Medication Safety Alert! Acute Care Edition. January 11, 2007;12:1-3.
https://psnet.ahrq.gov/issue/anticoagulant-safety-takes-center-stage-2007
This article, which launches a series focusing on high-alert medications, discusses issues related to
hep…
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psnet.ahrq.gov/node/35591/psn-pdf
December 21, 2005 - WHO Draft Guidelines for Adverse Event Reporting and
Learning Systems.
December 21, 2005
World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2005.
https://psnet.ahrq.gov/issue/who-draft-guidelines-adverse-event-reporting-and-learning-systems
These guidelines present background on the…