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psnet.ahrq.gov/issue/meta-review-methods-measuring-and-monitoring-safety-primary-care
November 03, 2021 - Review
A meta-review of methods of measuring and monitoring safety in primary care.
Citation Text:
O’Connor P, Madden C, O’Dowd E, et al. A meta-review of methods of measuring and monitoring safety in primary care. Int J Qual Health Care. 2021;33(3):mzab117. doi:10.1093/intqhc/mzab117.
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - This suggests that the
clinicians initially considered trauma but prematurely narrowed their focus to
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - Delay in Appropriate Diagnosis and Treatment Leading to
Death from Pulmonary Embolism
February 10, 2021
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary
Embolism. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leadi…
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psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
December 31, 2024 - SPOTLIGHT CASE
Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism
Citation Text:
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
July 17, 2024 - SPOTLIGHT CASE
Tough Call: Addressing Errors From Previous Providers
Citation Text:
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - SPOTLIGHT CASE
Out of Sight, Out of Mind: Out-of-Office Test Result Management
Citation Text:
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing
October 30, 2019
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
Case Objectives
List the most common errors associated with computerized…
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - A Double “Never Event”: Wrong Patient and Wrong Side.
Citation Text:
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
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psnet.ahrq.gov/node/49811/psn-pdf
November 01, 2017 - Delayed Diagnosis of Endocrinologic Emergencies
November 1, 2017
Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
The Cases
Case #1:
A 47-year-old man with a history of hyperthyroidism and h…
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
March 27, 2024
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and
Emergency Hysterectomy. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
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psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
November 16, 2022 - Annual Perspective
Annual Perspective: Psychological Safety of Healthcare Staff
March 31, 2022
View more articles from the same authors.
Citation Text:
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. P…
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psnet.ahrq.gov/issue/learning-lawsuits-using-malpractice-claims-data-develop-care-transitions-planning-tools
January 21, 2019 - Study
Learning from lawsuits: using malpractice claims data to develop care transitions planning tools.
Citation Text:
Arbaje AI, Werner NE, Kasda EM, et al. Learning From Lawsuits: Using Malpractice Claims Data to Develop Care Transitions Planning Tools. J Patient Saf. 2020;16(1):52-57.…
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psnet.ahrq.gov/issue/impact-drug-shortage-medication-errors-and-clinical-outcomes-pediatric-intensive-care-unit
November 16, 2022 - Study
Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.
Citation Text:
Hughes KM, Goswami ES, Morris JL. Impact of a Drug Shortage on Medication Errors and Clinical Outcomes in the Pediatric Intensive Care Unit. J Pediatr Pharmacol…
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psnet.ahrq.gov/issue/effect-electronic-transmission-prescriptions-dispensing-errors-and-prescription-enhancements
December 16, 2020 - Study
The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.
Citation Text:
Franklin BD, Reynolds M, Sadler S, et al. The effect of the electronic transmission…
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psnet.ahrq.gov/issue/work-hour-restrictions-ethical-dilemma-residents
April 24, 2018 - Study
Work-hour restrictions as an ethical dilemma for residents.
Citation Text:
Carpenter RO, Austin MT, Tarpley JL, et al. Work-hour restrictions as an ethical dilemma for residents. Am J Surg. 2006;191(4):527-32.
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Format:
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psnet.ahrq.gov/issue/performance-trigger-tool-identifying-adverse-events-oncology
May 23, 2018 - Study
Performance of a trigger tool for identifying adverse events in oncology.
Citation Text:
Lipitz-Snyderman A, Classen D, Pfister D, et al. Performance of a Trigger Tool for Identifying Adverse Events in Oncology. J Oncol Pract. 2017;13(3). doi:10.1200/jop.2016.016634.
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psnet.ahrq.gov/issue/questionable-hospital-chart-documentation-practices-physicians
August 10, 2011 - Study
Questionable hospital chart documentation practices by physicians.
Citation Text:
Sharma R, Kostis WJ, Wilson AC, et al. Questionable hospital chart documentation practices by physicians. J Gen Intern Med. 2008;23(11):1865-70. doi:10.1007/s11606-008-0750-6.
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Fo…
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psnet.ahrq.gov/issue/communication-safe-caregiving-between-community-nurse-case-managers-and-family-caregivers
March 09, 2022 - Study
Communication on safe caregiving between community nurse case managers and family caregivers.
Citation Text:
Macías-Colorado ME, Rodríguez-Pérez M, Rojas-Ocaña MJ, et al. Communication on safe caregiving between community nurse case managers and family caregivers. Healthcare (Basel…
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psnet.ahrq.gov/issue/acute-care-nurses-perceptions-leadership-teamwork-turnover-intention-and-patient-safety-mixed
September 16, 2015 - Study
Acute care nurses' perceptions of leadership, teamwork, turnover intention and patient safety - a mixed methods study.
Citation Text:
Zaheer S, Ginsburg LR, Wong HJ, et al. Acute care nurses’ perceptions of leadership, teamwork, turnover intention and patient safety – a mixed metho…
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psnet.ahrq.gov/issue/investigating-hospital-supervision-case-study-regulatory-inspectors-roles-potential-co
September 23, 2020 - Study
Investigating hospital supervision: a case study of regulatory inspectors' roles as potential co-creators of resilience.
Citation Text:
Øyri SF, Braut GS, Macrae C, et al. Investigating Hospital Supervision: A Case Study of Regulatory Inspectors’ Roles as Potential Co-creators of R…