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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - and Quality (AHRQ) recognizes that revitalizing the nation’s primary care system is foundational to achieving
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
June 28, 2023
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue
Necrosis and Cuff Rupture. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - can lead to clinician reluctance to take over for automated systems when technology protocols are not achieving
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psnet.ahrq.gov/node/850675/psn-pdf
June 14, 2023 - although this term does not have a standard definition and may not
describe the best practices for achieving
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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - How many attempts were made before achieving access?
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - In Conversation with...James P. Bagian, MD
September 1, 2006
Also Read an Essay
Also Read an Essay
Citation Text:
In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.In Conversation with...James P. Bagian, MD. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/issue/communicating-findings-delayed-diagnostic-evaluation-primary-care-providers
June 21, 2016 - Study
Communicating findings of delayed diagnostic evaluation to primary care providers.
Citation Text:
Meyer AND, Murphy DR, Singh H. Communicating Findings of Delayed Diagnostic Evaluation to Primary Care Providers. J Am Board Fam Med. 2016;29(4):469-73. doi:10.3122/jabfm.2016.04.15036…
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psnet.ahrq.gov/issue/process-failures-increase-risk-infection-through-respiratory-droplets-study-patient-safety
March 24, 2021 - Study
Process failures that increase the risk of infection through respiratory droplets: a study of patient safety events reported by hospitals across Pennsylvania.
Citation Text:
Harper A, Kukielka E, Jones RM. Process failures that increase the risk of infection through respiratory dro…
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psnet.ahrq.gov/issue/patient-specific-electronic-decision-support-reduces-prescription-excessive-doses
November 02, 2010 - Study
Patient-specific electronic decision support reduces prescription of excessive doses.
Citation Text:
Seidling HM, Schmitt SPW, Bruckner T, et al. Patient-specific electronic decision support reduces prescription of excessive doses. Qual Saf Health Care. 2010;19(5):e15. doi:10.113…
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psnet.ahrq.gov/issue/review-alleged-patient-deaths-patient-wait-times-and-scheduling-practices-phoenix-va-health
May 01, 2015 - Book/Report
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.
Citation Text:
Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System. Washington, DC: VA Office o…
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psnet.ahrq.gov/issue/interim-report-review-vhas-patient-wait-times-scheduling-practices-and-alleged-patient-deaths
September 10, 2014 - Government Resource
Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.
Citation Text:
Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix H…
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psnet.ahrq.gov/issue/matching-michigan-2-year-stepped-interventional-programme-minimise-central-venous-catheter
April 29, 2015 - Study
'Matching Michigan': a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England.
Citation Text:
Bion J, Richardson A, Hibbert P, et al. 'Matching Michigan': a 2-year stepped interventional programme to …
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psnet.ahrq.gov/issue/implementation-hand-hygiene-health-care-facilities-results-who-hand-hygiene-self-assessment
September 09, 2020 - Study
Implementation of hand hygiene in health-care facilities: results from the WHO Hand Hygiene Self-Assessment Framework global survey 2019.
Citation Text:
de Kraker MEA, Tartari E, Tomczyk S, et al. Implementation of hand hygiene in health-care facilities: results from the WHO Hand H…
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psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis
September 23, 2020 - Study
"SWARMing" to improve patient care: a novel approach to root cause analysis.
Citation Text:
Li J, Boulanger B, Norton J, et al. "SWARMing" to Improve Patient Care: A Novel Approach to Root Cause Analysis. Jt Comm J Qual Patient Saf. 2015;41(11):494-501.
Copy Citation
Format: …
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psnet.ahrq.gov/issue/patients-and-families-teachers-mixed-methods-assessment-collaborative-learning-model-medical
July 12, 2017 - Study
Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention.
Citation Text:
Langer T, Martinez W, Browning DM, et al. Patients and families as teachers: a mixed methods assessment of a collaborative lea…
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psnet.ahrq.gov/issue/understanding-differences-electronic-health-record-ehr-use-linking-individual-physicians
November 17, 2015 - Study
Understanding differences in electronic health record (EHR) use: linking individual physicians' perceptions of uncertainty and EHR use patterns in ambulatory care.
Citation Text:
Lanham HJ, Sittig DF, Leykum LK, et al. Understanding differences in electronic health record (EHR) u…
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psnet.ahrq.gov/issue/postoperative-adverse-events-inconsistently-improved-world-health-organization-surgical
March 29, 2023 - Review
Classic
Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies.
Citation Text:
de Jager E, McKenna C, Bartlett L, et al. Postoperative adverse events in…
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psnet.ahrq.gov/issue/failure-utilize-functions-electronic-prescribing-system-and-subsequent-generation-technically
February 15, 2012 - Study
Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically preventable' computerized alerts.
Citation Text:
Baysari M, Reckmann MH, Li L, et al. Failure to utilize functions of an electronic prescribing system and the subsequent g…
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psnet.ahrq.gov/issue/situ-simulation-tool-longitudinally-identify-and-track-latent-safety-threats-structured
June 08, 2022 - Study
In situ simulation as a tool to longitudinally identify and track latent safety threats in a structured quality improvement initiative for SARS-CoV-2 airway management: a single-center study.
Citation Text:
Jafri FN, Yang CJ, Kumar A, et al. In situ simulation as a tool to longitud…
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psnet.ahrq.gov/issue/use-electronic-clinical-decision-support-system-primary-care-assess-inappropriate
October 21, 2020 - Study
Use of an electronic clinical decision support system in primary care to assess inappropriate polypharmacy in young seniors with multimorbidity: observational, descriptive, cross-sectional study
Citation Text:
Rogero-Blanco E, Lopez-Rodriguez JA, Sanz-Cuesta T, et al. Use of an ele…