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psnet.ahrq.gov/issue/technical-mistakes-during-acquisition-electrocardiogram
March 09, 2022 - Review
Technical mistakes during the acquisition of the electrocardiogram.
Citation Text:
García-Niebla J, Llontop-García P, Valle-Racero JI, et al. Technical mistakes during the acquisition of the electrocardiogram. Ann Noninvasive Electrocardiol. 2009;14(4):389-403. doi:10.1111/j.154…
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psnet.ahrq.gov/issue/barriers-implementation-patient-safety-systems-healthcare-institutions-leadership-and-policy
July 14, 2010 - Study
Barriers to implementation of patient safety systems in healthcare institutions: leadership and policy implications.
Citation Text:
Barriers to implementation of patient safety systems in healthcare institutions: leadership and policy implications. Akins RB, Cole BR. J Patient …
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psnet.ahrq.gov/issue/ensuring-medication-safety-consumers-ethnic-minority-backgrounds-need-address-unconscious
July 29, 2020 - Commentary
Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscious bias within health systems.
Citation Text:
Chauhan A, Walpola RL. Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscio…
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psnet.ahrq.gov/issue/barriers-self-reporting-patient-safety-incidents-paramedics-mixed-methods-study
November 16, 2022 - Study
Barriers to self-reporting patient safety incidents by paramedics: a mixed methods study.
Citation Text:
Sinclair JE, Austin MA, Bourque C, et al. Barriers to Self-Reporting Patient Safety Incidents by Paramedics: A Mixed Methods Study. Prehosp Emerg Care. 2018;22(6):762-772. doi:1…
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psnet.ahrq.gov/issue/evaluation-12-strategies-obtaining-second-opinions-improve-interpretation-breast
November 03, 2015 - Study
Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study.
Citation Text:
Elmore JG, Tosteson AN, Pepe MS, et al. Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histo…
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psnet.ahrq.gov/issue/opioid-prescribing-patterns-and-complications-dermatology-medicare-population
May 25, 2022 - Study
Opioid prescribing patterns and complications in the dermatology Medicare population.
Citation Text:
Cao S, Karmouta R, Li DG, et al. Opioid Prescribing Patterns and Complications in the Dermatology Medicare Population. JAMA Dermatol. 2018;154(3):317-322. doi:10.1001/jamadermatol.2…
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psnet.ahrq.gov/issue/defense-health-agency-should-improve-tracking-serious-adverse-medical-events-and-monitoring
July 11, 2018 - Book/Report
Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.
Citation Text:
Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up. Washington, DC: United St…
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psnet.ahrq.gov/issue/clinician-factors-associated-delayed-diagnosis-appendicitis
October 26, 2022 - Study
Clinician factors associated with delayed diagnosis of appendicitis.
Citation Text:
Michelson KA, McGarghan FLE, Patterson EE, et al. Clinician factors associated with delayed diagnosis of appendicitis. Diagnosis (Berl). 2023;10(2):183-186. doi:10.1515/dx-2022-0119.
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psnet.ahrq.gov/issue/role-racism-core-patient-safety-issue
March 18, 2020 - Newspaper/Magazine Article
The role of racism as a core patient safety issue.
Citation Text:
Feeley D, Torres T. The role of racism as a core patient safety issue. Healthcare Executive. 2020;35(1):58-61.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/issue/diagnostic-difficulty-and-error-primary-care-systematic-review
April 07, 2021 - Review
Diagnostic difficulty and error in primary care—a systematic review.
Citation Text:
Kostopoulou O, Delaney B, Munro CW. Diagnostic difficulty and error in primary care--a systematic review. Fam Pract. 2008;25(6):400-413. doi:10.1093/fampra/cmn071.
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Format:
…
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psnet.ahrq.gov/issue/patient-safety-achieving-new-standard-care-0
March 29, 2007 - Book/Report
Classic
Patient Safety: Achieving a New Standard of Care.
Citation Text:
Patient Safety: Achieving a New Standard of Care. Institute of Medicine (US) Committee on Data Standards for Patient Safety, Aspden P, Corrigan JM, Wolcott J, Erickson SM, e…
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psnet.ahrq.gov/issue/information-distortion-physicians-diagnostic-judgments
April 07, 2021 - Study
Information distortion in physicians' diagnostic judgments.
Citation Text:
Kostopoulou O, Russo E, Keenan G, et al. Information distortion in physicians' diagnostic judgments. Med Decis Making. 2012;32(6):831-9. doi:10.1177/0272989X12447241.
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Format:
DO…
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psnet.ahrq.gov/issue/quality-improvement-and-safety-pediatric-emergency-medicine
March 12, 2025 - Review
Quality improvement and safety in pediatric emergency medicine.
Citation Text:
Ku BC, Chamberlain JM, Shaw KN. Quality Improvement and Safety in Pediatric Emergency Medicine. Pediatr Clin North Am. 2018;65(6):1269-1281. doi:10.1016/j.pcl.2018.07.010.
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Format:
…
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psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defining-clinical-reasoning
June 26, 2019 - Commentary
Emerging Classic
Drawing boundaries: the difficulty in defining clinical reasoning.
Citation Text:
Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning. Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0…
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psnet.ahrq.gov/node/33679/psn-pdf
January 01, 2009 - Disclosure of Medical Error
January 1, 2009
Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/disclosure-medical-error
Perspective
Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts
advocate that greater discl…
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psnet.ahrq.gov/node/49842/psn-pdf
September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric
Emergency Equipment
September 1, 2018
Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet
[internet]. 2018.
https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
The Case
As part of…
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psnet.ahrq.gov/node/49520/psn-pdf
September 01, 2006 - DNR in the OR and Afterwards
September 1, 2006
Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
The Case
An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and
suffered a fractured femur. After initial eval…
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psnet.ahrq.gov/node/49510/psn-pdf
May 01, 2006 - Cups of Error
May 1, 2006
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/cups-error
The Case
An 87-year-old man was 5 days postoperative from a decompressive laminectomy. Although he suffered
from dementia, he remained alert and oriented with only mild short-term memory…
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psnet.ahrq.gov/node/33844/psn-pdf
October 01, 2017 - Health Care Worker Presenteeism: A Challenge for Patient
Safety
October 1, 2017
Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
Perspective
Introduction
Health care–as…
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psnet.ahrq.gov/node/49577/psn-pdf
January 01, 2009 - Are Two Insulin Pumps Better Than One?
January 1, 2009
Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one
The Case
A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass
graft surge…