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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - SPOTLIGHT CASE
A Room Without Orders
Citation Text:
Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/60267/psn-pdf
March 01, 2021 - Affordable Housing Community Offers Seniors Onsite
Health Care Coordination and Support, Reducing Hospital
Admissions and Falls and Improving Resident Health
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-h…
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - In Conversation with Timothy Vogus about High
Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization
(HRO) Principles and Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/persp…
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - SPOTLIGHT CASE
Getting to the Root of the Matter
Citation Text:
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - The Impact of Communication on Medication Errors
March 15, 2021
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors
The Case
A 93-year-old man with a history of chronic systolic heart failure…
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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - However, they realized that if you manage your work to achieve constant discovery—doing your work with
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psnet.ahrq.gov/perspective/lesson-vas-team-training-program
November 01, 2011 - Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability
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psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - for action, whereas the second approach establishes a foundation for learning mechanisms by which to achieve
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psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
May 22, 2017 - which is simply a shift in the dose–response curve so that people need more and more of the drug to achieve
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psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
November 01, 2011 - Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - We can only achieve that if we have some organizational agreements and alignment around these tools.
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - which is simply a shift in the dose–response curve so that people need more and more of the drug to achieve
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - We can only achieve that if we have some organizational agreements and alignment around these tools.
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - for action, whereas the second approach establishes a foundation for learning mechanisms by which to achieve
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - However, they realized that if you manage your work to achieve constant discovery—doing your work with
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psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
March 01, 2018 - In Conversation With… Linda Aiken, PhD, RN
March 1, 2018
Also Read an Essay
Citation Text:
In Conversation With… Linda Aiken, PhD, RN. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …
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psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
September 01, 2014 - In Conversation With… Rosemary Gibson, MSc
September 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
March 30, 2020 - Making Healthcare Safer III Report
March 30, 2020
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. Rockville (MD): Agency for Health…
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - Complications of ECMO During Transport
Citation Text:
Broman M. Complications of ECMO During Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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