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psnet.ahrq.gov/node/49572/psn-pdf
October 01, 2008 - Mistaken Identity
October 1, 2008
Hall LW. Mistaken Identity. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mistaken-identity
The Case
An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status
and a reported fall. After finding tenderness in her left hip, the p…
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psnet.ahrq.gov/node/49724/psn-pdf
January 01, 2015 - Bowel Injury After Laparoscopic Surgery
January 1, 2015
Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
The Case
A 30-year-old man presented to the hospital for a scheduled laparoscopic inguinal hernia repair with mes…
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles
Citation Text:
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
March 12, 2021 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport
Citation Text:
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Q…
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psnet.ahrq.gov/primer/electronic-health-records
March 15, 2025 - Electronic Health Records
Citation Text:
Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/primer/systems-approach
June 15, 2024 - Systems Approach
Citation Text:
Systems Approach. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downl…
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psnet.ahrq.gov/issue/importance-preparation-doctors-handovers-acute-medical-assessment-unit-hierarchical-task
March 02, 2011 - Study
The importance of preparation for doctors' handovers in an acute medical assessment unit: a hierarchical task analysis.
Citation Text:
Raduma-Tomàs MA, Flin R, Yule S, et al. The importance of preparation for doctors' handovers in an acute medical assessment unit: a hierarchical …
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psnet.ahrq.gov/node/45647/psn-pdf
February 22, 2017 - Bias in the ER. Doctors suffer from the same cognitive
distortions as the rest of us.
February 22, 2017
Lewis M. Nautilus. February 9, 2017.
https://psnet.ahrq.gov/issue/bias-er-doctors-suffer-same-cognitive-distortions-rest-us
Physicians' decision-making can be diminished when they are tired, distracted, or too n…
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psnet.ahrq.gov/issue/position-statement-criminalization-medical-error-and-call-action-prevent-patient-harm-error
December 02, 2020 - Organizational Policy/Guidelines
Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error.
Citation Text:
Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error. Cooper J, Thomas B…
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psnet.ahrq.gov/issue/adverse-event-reporting-tool-standardize-reporting-and-tracking-adverse-events-during
April 20, 2016 - Commentary
Adverse event reporting tool to standardize the reporting and tracking of adverse events during procedural sedation: a consensus document from the World SIVA International Sedation Task Force.
Citation Text:
Mason KP, Mason KP, Green SM, et al. Adverse event reporting tool t…
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psnet.ahrq.gov/node/60744/psn-pdf
July 29, 2020 - The NSTEMI Curbside Consultation
July 29, 2020
Villablanca AC, Wong GX. The NSTEMI Curbside Consultation. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for
Continuing Medical E…
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psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
August 01, 2007 - The PeaceHealth Governance Journey in Support of Quality and Safety
John L. Haughom,
MD | August 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and …
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psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH
April 1, 2009
Also Read an Essay
Citation Text:
In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009.In Conversation with...Mark Chassin, MD, MPP, MPH . PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/issue/improving-our-understanding-multi-tasking-healthcare-drawing-together-cognitive-psychology
July 19, 2018 - Review
Improving our understanding of multi-tasking in healthcare: drawing together the cognitive psychology and healthcare literature.
Citation Text:
Douglas HE, Raban MZ, Walter SR, et al. Improving our understanding of multi-tasking in healthcare: Drawing together the cognitive psycho…
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psnet.ahrq.gov/node/49826/psn-pdf
April 01, 2018 - events, the use of checklists can help
prompt team members to think through all options, complete tasks
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psnet.ahrq.gov/issue/innovation-patient-safety-new-task-design-reducing-patient-falls
January 04, 2010 - Study
Innovation in patient safety: a new task design in reducing patient falls.
Citation Text:
Tzeng H-M, Yin C-Y. Innovation in patient safety: a new task design in reducing patient falls. J Nurs Care Qual. 2008;23(1):34-42. doi:10.1097/01.NCQ.0000303803.07457.e5.
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…
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psnet.ahrq.gov/node/48145/psn-pdf
July 17, 2019 - Mental mayhem: the peril of multitasking in medicine.
July 17, 2019
Joseph R; Harry E.
https://psnet.ahrq.gov/issue/mental-mayhem-peril-multitasking-medicine
Multitasking can negatively affect cognitive load and diminish safety. This magazine article reports on how
multitasking can contribute to surgeon fatigue, b…
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psnet.ahrq.gov/node/37286/psn-pdf
December 23, 2011 - Different roles, same goal: risk and quality management
partnering for patient safety. By the ASHRM Monographs
Task Force.
December 23, 2011
Bokar V, Perry DG. Different Roles, Same Goal: Risk And Quality Management Partnering For Patient
Safety. By The Ashrm Monographs Task Force.; 2007:17-23, 25. doi:10.1002/jhr…
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psnet.ahrq.gov/node/41094/psn-pdf
January 25, 2012 - Adverse event reporting tool to standardize the reporting
and tracking of adverse events during procedural
sedation: a consensus document from the World SIVA
International Sedation Task Force.
January 25, 2012
Mason KP, Mason KP, Green SM, et al. Adverse event reporting tool to standardize the reporting and
track…
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psnet.ahrq.gov/node/38492/psn-pdf
September 12, 2016 - Practice advisory on anesthetic care for magnetic
resonance imaging: a report by the American Society of
Anesthesiologists Task Force on Anesthetic Care for
Magnetic Resonance Imaging.
September 12, 2016
Practice advisory on anesthetic care for magnetic resonance imaging: an updated report by the american
society…