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psnet.ahrq.gov/issue/flaw-medicine-addressing-racial-and-gender-disparities-critical-care
June 16, 2010 - Commentary
The flaw of medicine: addressing racial and gender disparities in critical care.
Citation Text:
Hilton EJ, Goff KL, Sreedharan R, et al. The flaw of medicine: addressing racial and gender disparities in critical care. Anesthesiol Clin. 2020;38(2):357-368. doi:10.1016/j.anclin.…
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psnet.ahrq.gov/issue/more-words-interpersonal-communication-cognitive-bias-and-diagnostic-errors
March 11, 2013 - Commentary
'More than words' - interpersonal communication, cognitive bias and diagnostic errors.
Citation Text:
Dahm MR, Williams M, Crock C. ‘More than words’ – Interpersonal communication, cognitive bias and diagnostic errors. Patient Educ Couns. 2022;105(1):252-256. doi:10.1016/j.pec…
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psnet.ahrq.gov/issue/rescue-me-saving-vulnerable-non-icu-patient-population
June 01, 2011 - Study
Rescue me: saving the vulnerable non-ICU patient population.
Citation Text:
Bader MK, Neal B, Johnson L, et al. Rescue me: saving the vulnerable non-ICU patient population. Jt Comm J Qual Patient Saf. 2009;35(4):199-205.
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psnet.ahrq.gov/issue/does-physicians-training-induce-overconfidence-hampers-disclosing-errors
October 21, 2009 - Study
Does physician's training induce overconfidence that hampers disclosing errors?
Citation Text:
Brezis M, Orkin-Bedolach Y, Fink D, et al. Does Physician's Training Induce Overconfidence That Hampers Disclosing Errors? J Patient Saf. 2019;15(4):296-298. doi:10.1097/PTS.0000000000000…
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psnet.ahrq.gov/issue/barriers-speaking-about-patient-safety-concerns
September 01, 2018 - Study
Barriers to speaking up about patient safety concerns.
Citation Text:
Etchegaray JM, Ottosen MJ, Dancsak T, et al. Barriers to speaking up about patient safety concerns. J Patient Saf. 2020;16(4):e230-e234. doi:10.1097/pts.0000000000000334.
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psnet.ahrq.gov/issue/effective-followership-standardized-algorithm-resolve-clinical-conflicts-and-improve-teamwork
March 13, 2013 - Commentary
Effective followership: a standardized algorithm to resolve clinical conflicts and improve teamwork.
Citation Text:
Sculli GL, Fore AM, Sine DM, et al. Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork. J Healthc Risk Manag. 20…
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psnet.ahrq.gov/issue/diagnostic-error-mental-health-review
October 19, 2012 - Review
Diagnostic error in mental health: a review.
Citation Text:
Bradford A, Meyer AND, Khan S, et al. Diagnostic error in mental health: a review. BMJ Qual Saf. 2024;33(10):663-672. doi:10.1136/bmjqs-2023-016996.
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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Despite Clues, Failed to Rescue
August 1, 2017
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
Case Objectives
Define failure to rescue.
Identify the main contributors to failure-to-rescue events.
Appreciate the ongoing areas of scien…
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psnet.ahrq.gov/issue/stard-2015-guidelines-reporting-diagnostic-accuracy-studies-explanation-and-elaboration
February 14, 2006 - Commentary
STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration.
Citation Text:
Cohen JF, Korevaar DA, Altman DG, et al. STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration. BMJ Open. 2016;6(11):e012799. doi…
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psnet.ahrq.gov/issue/situation-awareness-errors-anesthesia-and-critical-care-200-cases-critical-incident-reporting
August 03, 2017 - Study
Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system.
Citation Text:
Schulz CM, Krautheim V, Hackemann A, et al. Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting syste…
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psnet.ahrq.gov/issue/prospective-study-factors-influencing-outcome-patients-after-medical-emergency-team-review
March 05, 2010 - Study
A prospective study of factors influencing the outcome of patients after a Medical Emergency Team review.
Citation Text:
Calzavacca P, Licari E, Tee A, et al. A prospective study of factors influencing the outcome of patients after a Medical Emergency Team review. Intensive Care …
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psnet.ahrq.gov/issue/patient-led-training-patient-safety-pilot-study-test-feasibility-and-acceptability
April 24, 2017 - Study
Patient-led training on patient safety: a pilot study to test the feasibility and acceptability of an educational intervention.
Citation Text:
Jha V, Winterbottom A, Symons J, et al. Patient-led training on patient safety: a pilot study to test the feasibility and acceptability …
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psnet.ahrq.gov/issue/society-critical-care-medicine-guidelines-recognizing-and-responding-clinical-deterioration
April 24, 2018 - Organizational Policy/Guidelines
Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023.
Citation Text:
Honarmand K, Wax RS, Penoyer D, et al. Society of Critical Care Medicine Guidelines on Recognizing and Responding to…
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psnet.ahrq.gov/about-psnet
September 01, 2015 - Theoretical pieces should articulate foundational concepts that help readers understand the methods and
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psnet.ahrq.gov/issue/preventability-and-causes-readmissions-national-cohort-general-medicine-patients
January 25, 2017 - Study
Classic
Preventability and causes of readmissions in a national cohort of general medicine patients.
Citation Text:
Auerbach AD, Kripalani S, Vasilevskis EE, et al. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients…
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psnet.ahrq.gov/issue/hospital-based-medication-reconciliation-practices-systematic-review
April 05, 2013 - Review
Classic
Hospital-based medication reconciliation practices: a systematic review.
Citation Text:
Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-69. do…
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psnet.ahrq.gov/issue/patient-and-family-reporting-system-perceived-ambulatory-note-mistakes-experience-3-us
June 06, 2018 - Study
A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers.
Citation Text:
Bourgeois FC, Fossa A, Gerard M, et al. A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcar…
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psnet.ahrq.gov/web-mm/poor-prognosis
March 15, 2016 - Case Objectives
Understand the current limitations of physicians' ability to provide prognoses. … Study to understand prognoses and preferences for outcomes and risks of treatments.
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - He highlighted how hindsight bias can subvert efforts to understand causality in serious accidents.
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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