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psnet.ahrq.gov/node/49409/psn-pdf
July 01, 2003 - Feeling No Pain
July 1, 2003
Bogner MS. Feeling No Pain. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/feeling-no-pain
The Case
A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the
patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…
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psnet.ahrq.gov/node/867980/psn-pdf
March 25, 2025 - Not All Headaches are Due to Migraine: Red Flags, Don’t
Miss Diagnoses, and Diagnostic Pitfalls
March 25, 2025
Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic
Pitfalls. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-fla…
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psnet.ahrq.gov/Webmm/submit-case-info
August 10, 2025 - Selection Criteria and Honorarium Information
How it works
Health care professionals may submit de-identified cases that highlight medical errors or other patient
safety/quality
issues. Note that you can choose to submit cases either …
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psnet.ahrq.gov/node/33602/psn-pdf
March 15, 2025 - Individual Clinician Performance Issues
March 15, 2025
Individual Clinician Performance Issues. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/individual-clinician-performance-issues
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current res…
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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - Annual Perspective
Computerized Provider Order Entry and Patient Safety
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien…
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psnet.ahrq.gov/node/33593/psn-pdf
June 15, 2024 - Measurement of Patient Safety
June 15, 2024
Measurement of Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/measurement-patient-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient …
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psnet.ahrq.gov/node/866265/psn-pdf
July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to
Medication Error During Patient Transport
July 31, 2024
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During
Patient Transport. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…
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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication
Citation Text:
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. 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/issue/uptake-quality-related-event-standards-practice-community-pharmacies
November 09, 2016 - Study
Uptake of quality-related event standards of practice by community pharmacies.
Citation Text:
Boyle TA, Bishop A, Overmars C, et al. Uptake of Quality-Related Event Standards of Practice by Community Pharmacies. J Pharm Pract. 2015;28(5):442-9. doi:10.1177/0897190014522066.
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psnet.ahrq.gov/issue/surgeon-second-victim-results-boston-intraoperative-adverse-events-surgeons-attitude-bisa
January 23, 2017 - Study
The surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) study.
Citation Text:
Han K, Bohnen JD, Peponis T, et al. The surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) …
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psnet.ahrq.gov/issue/effects-physical-environments-medical-wards-medication-communication-processes-affecting
November 17, 2021 - Study
The effects of physical environments in medical wards on medication communication processes affecting patient safety.
Citation Text:
Liu W, Manias E, Gerdtz M. The effects of physical environments in medical wards on medication communication processes affecting patient safety. Heal…
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psnet.ahrq.gov/issue/rise-human-factors-optimising-performance-individuals-and-teams-improve-patients-outcomes
July 10, 2024 - Commentary
The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes.
Citation Text:
Casali G, Cullen W, Lock G. The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes. J Thorac Dis. 2019;11(…
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psnet.ahrq.gov/issue/implementing-standardized-reporting-and-safety-checklists
September 29, 2017 - Study
Implementing standardized reporting and safety checklists.
Citation Text:
Stevens JD, Bader MK, Luna MA, et al. Cultivating quality: implementing standardized reporting and safety checklists. Am J Nurs. 2011;111(5):48-53. doi:10.1097/01.naj.0000398051.07923.69.
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…
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psnet.ahrq.gov/issue/usability-and-feasibility-consumer-facing-technology-reduce-unsafe-medication-use-older
February 17, 2011 - Study
Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults.
Citation Text:
Holden RJ, Campbell NL, Abebe E, et al. Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults. Res Social Adm Ph…
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psnet.ahrq.gov/issue/ethnographic-study-classifying-and-accounting-risk-sharp-end-medical-wards
June 16, 2021 - Study
An ethnographic study of classifying and accounting for risk at the sharp end of medical wards.
Citation Text:
Dixon-Woods M, Suokas A, Pitchforth E, et al. An ethnographic study of classifying and accounting for risk at the sharp end of medical wards. Soc Sci Med. 2009;69(3):362…
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psnet.ahrq.gov/issue/bad-behavior-healthcare-insidious-threat-patients-staff-and-organizations
October 16, 2019 - Commentary
Bad behavior in healthcare: an insidious threat to patients, staff, and organizations.
Citation Text:
Crowe L, Riley CM. Bad behavior in healthcare: an insidious threat to patients, staff, and organizations. Curr Opin Cardiol. 2024;39(4):331-337. doi:10.1097/hco.00000000000011…
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psnet.ahrq.gov/issue/5-year-analysis-rapid-response-system-activation-hospital-haemodialysis-unit
March 24, 2011 - Study
A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit.
Citation Text:
Galhotra S, Devita MA, Dew MA, et al. A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit. Qual Saf Health Care. 2010;19(6):e38. doi:1…
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psnet.ahrq.gov/issue/use-anatomical-side-markers-general-radiology-systematic-review-current-literature
October 21, 2020 - Review
The use of anatomical side markers in general radiology: a systematic review of the current literature.
Citation Text:
Chung L, Kumar S, Oldfield J, et al. The use of anatomical side markers in general radiology: a systematic review of the current literature. J Patient Saf. 2022;1…
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psnet.ahrq.gov/issue/crises-clinical-care-approach-management
March 23, 2011 - Commentary
Crises in clinical care: an approach to management.
Citation Text:
Runciman WB. Crises in clinical care: an approach to management. Quality and Safety in Health Care. 2005;14(3). doi:10.1136/qshc.2004.012856.
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Format:
DOI Google Scholar BibTeX EndN…
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psnet.ahrq.gov/issue/crisis-management-surgical-wards-simulation-based-approach-enhancing-technical-teamwork-and
January 27, 2012 - Study
Crisis management on surgical wards: a simulation-based approach to enhancing technical, teamwork, and patient interaction skills.
Citation Text:
Arora S, Hull L, Fitzpatrick M, et al. Crisis management on surgical wards: a simulation-based approach to enhancing technical, teamwork…