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psnet.ahrq.gov/issue/partnership-healthcare-excellence
October 26, 2020 - Multi-use Website
The Partnership for Healthcare Excellence.
Citation Text:
The Partnership for Healthcare Excellence.
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Novemb…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.17_slideshow.ppt
June 01, 2003 - PowerPoint Presentation
Spotlight Case June 2003
Missed Appendicitis
webmm.ahrq.gov
Source and Credits
This presentation is based on June 2003
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: James Adams, MD, Fei…
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psnet.ahrq.gov/node/49667/psn-pdf
October 01, 2012 - Looking for Meds in All the Wrong Places
October 1, 2012
Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
The Case
A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She
went to t…
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psnet.ahrq.gov/node/33655/psn-pdf
August 01, 2007 - The PeaceHealth Governance Journey in Support of
Quality and Safety
August 1, 2007
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and Safety. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
Perspective
In recent years, the…
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psnet.ahrq.gov/periodic-issue/periodic-issue-404
August 30, 2023 - Patient safety in palliative care at the end of life from the perspective of complex thinking
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - April 20, 2022
Perspective
Innovation and Lean Thinking
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psnet.ahrq.gov/web-mm/lost-transition
November 17, 2010 - Canadian ED physician and safety expert Pat Croskerry’s observation, “When the diagnosis is made, the thinking
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - to the short half-life, repeat doses of naloxone may be necessary to
provide continued reversal.18
Thinking
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psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - Course content includes (but not limited to): systems failure and medical errors, process and outcomes thinking
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - If it was offered, he may have refused it, thinking that his prescription was for his usual refill.
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psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
December 23, 2020 - Design thinking. Harv Bus Rev. 2008;86:84-92, 141. [go to PubMed] 7. Fox S. Degrees of access.
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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - December 14, 2022
Thinking in three's: changing surgical patient safety practices
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psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-intermittent-episodes-dizziness-and-headache
February 08, 2023 - dizziness”, “vertigo”, “imbalance”, “lightheadedness” and others) is not as diagnostically useful as once thought … The patient in this case endorsed “imbalance”, but the clinician should be thinking of the differential … The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking
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psnet.ahrq.gov/node/49502/psn-pdf
February 01, 2006 - A thought-experiment of walking through the frequently nurse-driven activation of
a code—including how
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psnet.ahrq.gov/web-mm/toxic-tachycardia
March 01, 2005 - The persistently rapid heart rate, probably thought to be a response to her abdominal pain, was a clue
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psnet.ahrq.gov/node/49813/psn-pdf
January 01, 2018 - The family had thought their doctor had been informed
of their mother's death and assumed that the PCP … This case illustrates the fallacy of this thinking.
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psnet.ahrq.gov/issue/healthcare-411-patient-safety-organizations-proposed-regulation
April 25, 2018 - Audiovisual
Healthcare 411: Patient Safety Organizations Proposed Regulation.
Citation Text:
Agency for Healthcare Research and Quality; AHRQ.
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psnet.ahrq.gov/node/33848/psn-pdf
December 01, 2017 - The Evolution of Patient Safety in Surgery
December 1, 2017
Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
Perspective
In 1979, 20 years before the Institute of Medicine's To Err Is Human report (1) catalyzed the cr…
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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/49488/psn-pdf
August 21, 2005 - PCA Overdose
August 21, 2005
Doyle JD. PCA Overdose. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pca-overdose
The Case
A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo-
oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…