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psnet.ahrq.gov/issue/randomised-controlled-trial-assess-effect-just-time-training-procedural-performance-proof
May 31, 2017 - Study
Randomised controlled trial to assess the effect of a Just-in-Time training on procedural performance: a proof-of-concept study to address procedural skill decay.
Citation Text:
Branzetti JB, Adedipe AA, Gittinger MJ, et al. Randomised controlled trial to assess the effect of a Jus…
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psnet.ahrq.gov/node/847732/psn-pdf
April 19, 2023 - Saving Moms.
April 19, 2023
Boswell B. KCET: April 2023.
https://psnet.ahrq.gov/issue/saving-moms
Increasing attention is being placed on addressing inequities in maternal health care. This video shares
stories of mothers experiencing harm during pregnancy and steps being taken to minimize the impact of
implicit …
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psnet.ahrq.gov/node/41655/psn-pdf
February 01, 2015 - Do No Harm: Jess's Story.
February 1, 2015
Barnett T, Barnett P.
https://psnet.ahrq.gov/issue/project-jessica
This video chronicles how an undiagnosed heart condition led to a teenager's death and offers tips for
patients to prevent medical errors.
https://psnet.ahrq.gov/issue/project-jessica
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/35293/psn-pdf
August 31, 2005 - Removing Insult from Injury: Disclosing Adverse Events.
August 31, 2005
Johns Hopkins Bloomberg School of Public Health
https://psnet.ahrq.gov/issue/removing-insult-injury-disclosing-adverse-events
This 25-minute training video illustrates how physicians can discuss and apologize for medical mistakes.
https://psne…
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psnet.ahrq.gov/node/36625/psn-pdf
November 21, 2016 - When Things Go Wrong: Voices of Patients and Families.
November 21, 2016
CRICO/RMF; Harvard Risk Management Foundation
https://psnet.ahrq.gov/issue/when-things-go-wrong-voices-patients-and-families
This educational video shares patient and family perspectives on how medical error affected their lives.
https://psne…
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psnet.ahrq.gov/issue/proficiency-based-virtual-reality-training-significantly-reduces-error-rate-residents-during
November 13, 2009 - Study
Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies.
Citation Text:
Ahlberg G, Enochsson L, Gallagher AG, et al. Proficiency-based virtual reality training significantly reduces the err…
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psnet.ahrq.gov/node/72557/psn-pdf
December 09, 2020 - The diagnostic moment: a study in US primary care.
December 9, 2020
Heritage J. The diagnostic moment: a study in US primary care. Soc Sci Med. 2019;228:262-271.
doi:10.1016/j.socscimed.2019.03.022.
https://psnet.ahrq.gov/issue/diagnostic-moment-study-us-primary-care
This article discusses the concept of the “diag…
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psnet.ahrq.gov/node/73456/psn-pdf
June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult
Intubation and Severe Hypoxemia
June 30, 2021
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - clear communication, including (1) Using plain languages and visual aids, such as models,
pictures, or videos
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psnet.ahrq.gov/node/849611/psn-pdf
May 31, 2023 - Voices from the Frontlines of Health Care Safety.
May 31, 2023
Boston, MA; Betsy Lehman Center for Patient Safety; April 2023.
https://psnet.ahrq.gov/issue/voices-frontlines-health-care-safety
Well-told stories can motivate change. This video translates the experience of Massachusetts patients and
family members w…
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psnet.ahrq.gov/node/37356/psn-pdf
December 13, 2017 - Transforming Hospitals: Designing for Safety and Quality.
December 13, 2017
Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
https://psnet.ahrq.gov/issue/transforming-hospitals-designing-safety-and-quality
This video uses the experiences of three US hospitals to demonstrate how the quality …
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psnet.ahrq.gov/node/867190/psn-pdf
November 20, 2024 - Misdiagnosis is dangerous. Help your doctor get it right.
November 20, 2024
Terry K. Misdiagnosis is dangerous. Help your doctor get it right. WebMD. November 11, 2024;
https://psnet.ahrq.gov/issue/misdiagnosis-dangerous-help-your-doctor-get-it-right
Patients are partners in health care and can inform actions to id…
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psnet.ahrq.gov/issue/variations-gps-decisions-investigate-suspected-lung-cancer-factorial-experiment-using
August 03, 2022 - Study
Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes.
Citation Text:
Sheringham J, Sequeira R, Myles J, et al. Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia …
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - Simplifying information with plain language and visual cues, such as models, pictures, or videos.
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psnet.ahrq.gov/node/853445/psn-pdf
December 15, 2022 - Jake Tapper shares harrowing story of daughter's near-
fatal misdiagnosis.
December 15, 2022
CNN. December 15, 2022.
https://psnet.ahrq.gov/issue/jake-tapper-shares-harrowing-story-daughters-near-fatal-misdiagnosis
Diagnostic errors are a recognized cause of preventable patient harm. This video highlights a teen’…
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psnet.ahrq.gov/issue/surgical-checklist-implementation-project-impact-variable-who-checklist-compliance-risk
June 22, 2016 - Study
Surgical checklist implementation project: the impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national implementation: a longitudinal study.
Citation Text:
Mayer EK, Sevdalis N, Rout S, et al. Surgical Checklist Implementation Project: The Impa…
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psnet.ahrq.gov/issue/association-between-exposure-nonactionable-physiologic-monitor-alarms-and-response-time
August 20, 2014 - Study
Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospital.
Citation Text:
Bonafide CP, Lin R, Zander M, et al. Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospit…
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psnet.ahrq.gov/issue/development-online-morbidity-mortality-and-near-miss-reporting-system-identify-patterns
August 20, 2018 - Study
Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients.
Citation Text:
Bilimoria KY, Kmiecik TE, DaRosa DA, et al. Development of an online morbidity, mortality, and near-miss reporting system to ide…
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psnet.ahrq.gov/issue/using-incident-reports-assess-communication-failures-and-patient-outcomes
February 06, 2019 - Study
Using incident reports to assess communication failures and patient outcomes.
Citation Text:
Umberfield E, Ghaferi AA, Krein SL, et al. Using Incident Reports to Assess Communication Failures and Patient Outcomes. Jt Comm J Qual Patient Saf. 2019;45(6):406-413. doi:10.1016/j.jcjq.2…