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psnet.ahrq.gov/node/35715/psn-pdf
February 15, 2006 - Changes in intensive care unit nurse task activity after
installation of a third-generation intensive care unit
information system.
February 15, 2006
Wong DH; Gallegos Y; Weinger MB; Clack S; Slagle J; Anderson CT.
https://psnet.ahrq.gov/issue/changes-intensive-care-unit-nurse-task-activity-after-installation-thir…
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psnet.ahrq.gov/node/34954/psn-pdf
June 23, 2009 - Active surveillance of vaccine safety: a system to detect
early signs of adverse events.
June 23, 2009
Davis RL, Kolczak M, Lewis E, et al. Active surveillance of vaccine safety: a system to detect early signs of
adverse events. Epidemiology. 2005;16(3):336-41.
https://psnet.ahrq.gov/issue/active-surveillance-vacc…
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psnet.ahrq.gov/node/39580/psn-pdf
January 03, 2017 - Evolution of a rapid response system from voluntary to
mandatory activation.
January 3, 2017
Jones CM, Bleyer AJ, Petree B. Evolution of a rapid response system from voluntary to mandatory
activation. Jt Comm J Qual Patient Saf. 2010;36(6):266-70, 241.
https://psnet.ahrq.gov/issue/evolution-rapid-response-system-v…
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psnet.ahrq.gov/node/40294/psn-pdf
September 24, 2016 - Hospital doctors' workflow interruptions and activities: an
observation study.
September 24, 2016
Weigl M, Müller A, Zupanc A, et al. Hospital doctors' workflow interruptions and activities: an observation
study. BMJ Qual Saf. 2011;20(6):491-7. doi:10.1136/bmjqs.2010.043281.
https://psnet.ahrq.gov/issue/hospital-d…
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psnet.ahrq.gov/node/46231/psn-pdf
December 20, 2017 - Patient preferences for participation in patient care and
safety activities in hospitals.
December 20, 2017
Ringdal M, Chaboyer W, Ulin K, et al. Patient preferences for participation in patient care and safety
activities in hospitals. BMC Nurs. 2017;16:69. doi:10.1186/s12912-017-0266-7.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case July 2004
Preventing Inappropriate Use of Novel Therapeutic Agents
Source and Credits
This presentation is based on the July 2004 AHRQ WebM&M Spotlight Case in Critical Care Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the W…
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psnet.ahrq.gov/node/838136/psn-pdf
September 21, 2022 - Exploration of a rapid response team model of care: a
descriptive dual methods study.
September 21, 2022
Shiell A, Fry M, Elliott D, et al. Exploration of a rapid response team model of care: a descriptive dual
methods study. Intensive Crit Care Nurs. 2022;73:103294. doi:10.1016/j.iccn.2022.103294.
https://psnet.a…
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psnet.ahrq.gov/node/39859/psn-pdf
November 21, 2016 - Experience with family activation of rapid response
teams.
November 21, 2016
Bogert S, Ferrell C, Rutledge DN. Experience with family activation of rapid response teams. Medsurg
Nurs. 2010;19(4):215-22; quiz 223.
https://psnet.ahrq.gov/issue/experience-family-activation-rapid-response-teams
The central tenet behi…
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - SPOTLIGHT CASE
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.
Citation Text:
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
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psnet.ahrq.gov/issue/agency-information-collection-activities-assessing-impact-national-implementation-teamstepps
July 03, 2013 - Press Release/Announcement
Agency information collection activities: Assessing the Impact of the National Implementation of TeamSTEPPS Master Training Program; comment request.
Citation Text:
Agency information collection activities: Assessing the Impact of the National Implementation …
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psnet.ahrq.gov/issue/developing-and-evaluating-trigger-response-system
August 29, 2018 - Study
Developing and evaluating a trigger response system.
Citation Text:
Cherry K, Martinek J, Esleck S, et al. Developing and Evaluating a Trigger Response System. The Joint Commission Journal on Quality and Patient Safety. 2016;35(6). doi:10.1016/s1553-7250(09)35047-3.
Copy Citation…
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psnet.ahrq.gov/issue/effect-staged-emergency-department-specific-rapid-response-system-reporting-clinical
March 24, 2021 - Study
The effect of a staged, emergency department specific rapid response system on reporting of clinical deterioration.
Citation Text:
Considine J, Rawet J, Currey J. The effect of a staged, emergency department specific rapid response system on reporting of clinical deterioration. Aus…
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psnet.ahrq.gov/issue/well-defined-pediatric-icu-active-surveillance-using-nonmedical-personnel-capture-less
July 13, 2010 - Study
The well-defined pediatric ICU: active surveillance using nonmedical personnel to capture less serious safety events.
Citation Text:
White WA, Kennedy K, Belgum HS, et al. The Well-Defined Pediatric ICU: Active Surveillance Using Nonmedical Personnel to Capture Less Serious Safety …
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psnet.ahrq.gov/node/60867/psn-pdf
September 02, 2020 - Clarifying radiology's role in safety events: a 5-year
retrospective common cause analysis of safety events at
a pediatric hospital.
September 2, 2020
Khalatbari H, Menashe SJ, Otto RK, et al. Clarifying radiology’s role in safety events: a 5-year retrospective
common cause analysis of safety events at a pediatric…
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psnet.ahrq.gov/node/72521/psn-pdf
December 02, 2020 - I-PASS illness diversity identifies patients at risk for
overnight clinical deterioration.
December 2, 2020
Shah C, Sanber K, Jacobson R, et al. I-PASS illness diversity identifies patients at risk for overnight clinical
deterioration. J Grad Med Educ. 2020;12(5):578-582. doi:10.4300/jgme-d-19-00755.1.
https://psn…
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psnet.ahrq.gov/node/48101/psn-pdf
August 14, 2019 - Partnering with families and patient advocates: another
line of defense in adverse event surveillance.
August 14, 2019
ISMP Medication Safety Alert! Acute Care Edition. August 1, 2019;24.
https://psnet.ahrq.gov/issue/partnering-families-and-patient-advocates-another-line-defense-adverse-event-
surveillance
Having…
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psnet.ahrq.gov/node/49824/psn-pdf
March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous
Delay
March 1, 2018
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
The Case
A 35-year-old woman with no prior cardiac history calle…
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psnet.ahrq.gov/issue/impact-implementation-family-initiated-escalation-care-deteriorating-patient-hospital
December 21, 2018 - Review
The impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review.
Citation Text:
Gill FJ, Leslie GD, Marshall AP. The Impact of Implementation of Family-Initiated Escalation of Care for the Deteriorating Patient in …
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psnet.ahrq.gov/node/34794/psn-pdf
November 18, 2015 - Accident analysis of large-scale technological disasters
applied to an anaesthetic complication.
November 18, 2015
Eagle CJ, Davies JM, Reason J. Accident analysis of large-scale technological disasters applied to an
anaesthetic complication. Can J Anaesth. 1992;39(2):118-22.
https://psnet.ahrq.gov/issue/accident-…
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - processes surrounding identifying, reporting, and analyzing medication errors, all organizations should actively