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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - Missed CANDOR Implementation Opportunities.
Citation Text:
Schweitzer L. Missed CANDOR Implementation Opportunities.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/Information/Editor
May 23, 2025 - Browse Author Resources
Meet PSNet's Editorial Team The PSNet editorial team is committed to producing the highest quality patient safety content. The team brings a wealth of experience and deep subject matter expertise in the field, ensuring that PSNet content is accurate, reliable, and…
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psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
January 13, 2021 - Delayed Sepsis Management Due to Ambiguous Allergy
Citation Text:
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking
January 26, 2022
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
Disclosure of Relevant Financial Relationships: As a provider ac…
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Patient Safety Events Involving Opioid
Dose Stacking
Source and Credits
• This presentation is based on the January 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
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psnet.ahrq.gov/node/865610/psn-pdf
April 24, 2024 - Suicide Prevention in an Emergency Department
Population: ED-SAFE
April 24, 2024
https://psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
Summary
Suicide is the 12th leading cause of death in the United States, and the 3rd leading cause of death for
people ages 15-24.1 More tha…
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psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout
Citation Text:
Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/node/854849/psn-pdf
October 31, 2023 - “Copy and Paste” Notes and Autopopulated Text in the
Electronic Health Records
October 31, 2023
MacDonald S. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
Th…
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - Missed CANDOR Implementation Opportunities.
November 16, 2022
Schweitzer L. Missed CANDOR Implementation Opportunities. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
The Case
A 58-year-old man with a history of type 2 diabetes mellitus, hypertension, morbid obesit…
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psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
July 17, 2024 - SPOTLIGHT CASE
Tough Call: Addressing Errors From Previous Providers
Citation Text:
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - SPOTLIGHT CASE
Errors in Sepsis Management
Citation Text:
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
August 01, 2014 - So the problem of analyzing the data, making it meaningful, and integrating it into physician workflow
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - initiatives such as the implementation of patient safety bundles and taking a systems approach to analyzing
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Information technology (IT) is integral to a successful learning health system, especially for collecting and analyzing
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psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workforce-challenges
August 30, 2023 - After analyzing COVID-19 telehealth implementation through a human factors approach , researchers have
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psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schuelke-about-virtual-nursing
August 30, 2023 - After analyzing COVID-19 telehealth implementation through a human factors approach , researchers have
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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - Information technology (IT) is integral to a successful learning health system, especially for collecting and analyzing
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - initiatives such as the implementation of patient safety bundles and taking a systems approach to analyzing
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psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
August 22, 2014 - So the problem of analyzing the data, making it meaningful, and integrating it into physician workflow
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psnet.ahrq.gov/node/49792/psn-pdf
May 01, 2017 - Diagnostic Delay in the Emergency Department
May 1, 2017
Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
Case Objectives
Appreciate the importance of a broad differential diagnosis for acute abdominal pai…