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psnet.ahrq.gov/web-mm/discharged-blindly
October 26, 2022 - monitoring devices, pill minders, talking watches, various magnification devices, and computers with voice capabilities
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psnet.ahrq.gov/node/50393/psn-pdf
September 01, 2019 - functional, innovative site that has evolved as
our user needs have expanded and the technological capabilities
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psnet.ahrq.gov/issue/standardized-competencies-parenteral-nutrition-administration-aspen-model
June 12, 2018 - Organizational Policy/Guidelines
Standardized Competencies for Parenteral Nutrition Administration: the ASPEN Model.
Citation Text:
Guenter P, Worthington P, Ayers P, et al. Standardized Competencies for Parenteral Nutrition Administration: The ASPEN Model. Nutr Clin Pract. 2018;33(2):29…
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psnet.ahrq.gov/issue/working-conditions-support-patient-safety
June 23, 2009 - Commentary
Working conditions that support patient safety.
Citation Text:
Hughes RG, Clancy CM. Working conditions that support patient safety. J Nurs Care Qual. 2005;20(4):289-292.
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psnet.ahrq.gov/issue/building-safer-foundation-lessons-learnt-patient-safety-training-programme
July 22, 2013 - Study
Building a safer foundation: the Lessons Learnt patient safety training programme.
Citation Text:
Ahmed M, Arora S, Tiew S, et al. Building a safer foundation: the Lessons Learnt patient safety training programme. BMJ Qual Saf. 2014;23(1):78-86. doi:10.1136/bmjqs-2012-001740.
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psnet.ahrq.gov/issue/reengineering-hospital-discharge-protocol-improve-patient-safety-reduce-costs-and-boost
May 20, 2009 - Commentary
Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction.
Citation Text:
Clancy CM. Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction. Am J Med Qual…
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psnet.ahrq.gov/issue/case-based-learning-patient-safety-lessons-learnt-program-uk-junior-doctors
July 15, 2015 - Commentary
Case-based learning for patient safety: the Lessons Learnt program for UK junior doctors.
Citation Text:
Ahmed M, Arora S, Baker P, et al. Case-based learning for patient safety: the Lessons Learnt program for UK junior doctors. World J Surg. 2012;36(5):956-8. doi:10.1007/s0…
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psnet.ahrq.gov/issue/junior-doctors-reflections-patient-safety
July 15, 2015 - Study
Junior doctors' reflections on patient safety.
Citation Text:
Ahmed M, Arora S, Carley S, et al. Junior doctors' reflections on patient safety. Postgrad Med J. 2012;88(1037):125-9. doi:10.1136/postgradmedj-2011-130301.
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psnet.ahrq.gov/issue/clinical-faculty-taking-lead-teaching-quality-improvement-and-patient-safety
July 01, 2017 - Commentary
Clinical faculty: taking the lead in teaching quality improvement and patient safety.
Citation Text:
Davis NL, Davis DA, Rayburn WF. Clinical faculty: taking the lead in teaching quality improvement and patient safety. Am J Obstet Gynecol. 2014;211(3):215-215.e1. doi:10.1016/j…
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psnet.ahrq.gov/issue/limiting-nurse-overtime-and-promoting-other-good-working-conditions-influences-patient-safety
June 23, 2009 - Commentary
Limiting nurse overtime, and promoting other good working conditions, influences patient safety.
Citation Text:
Sharp BAC, Clancy CM. Limiting nurse overtime, and promoting other good working conditions, influences patient safety. J Nurs Care Qual. 2008;23(2):97-100. doi:10.…
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psnet.ahrq.gov/issue/understanding-vs-competency-case-accuracy-checking-dispensed-medicines-pharmacy
December 11, 2013 - Study
Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy.
Citation Text:
James L, Davies G, Kinchin I, et al. Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy. Adv Health Sci Educ Theory Pract. 2010;15(…
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psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - may require continuous calibration, as the educational supervisor becomes more aware of the learner's capabilities
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psnet.ahrq.gov/issue/relationships-between-pediatric-safety-indicators-across-national-sample-pediatric-hospitals
April 06, 2022 - Study
Relationships between pediatric safety indicators across a national sample of pediatric hospitals: dispelling the myth of the "safest" hospital.
Citation Text:
Milliren CE, Bailey G, Graham DA, et al. Relationships between pediatric safety indicators across a national sample of ped…
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psnet.ahrq.gov/issue/care-quality-patient-safety-and-nurse-outcomes-hospitals-serving-economically-disadvantaged
December 09, 2020 - Study
Care quality, patient safety, and nurse outcomes at hospitals serving economically disadvantaged patients: a case for investment in nursing.
Citation Text:
Viscardi MK, French R, Brom H, et al. Care quality, patient safety, and nurse outcomes at hospitals serving economically disad…
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psnet.ahrq.gov/issue/disparate-perspectives-exploring-healthcare-professionals-misaligned-mental-models-older
May 11, 2022 - Study
Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility.
Citation Text:
Werner NE, Rutkowski RA, Krause S, et al. Disparate perspectives: exploring health…
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psnet.ahrq.gov/issue/using-claims-data-based-sentinel-system-improve-compliance-clinical-guidelines-results
October 19, 2022 - Study
Using a claims data-based sentinel system to improve compliance with clinical guidelines: results of a randomized prospective study.
Citation Text:
Javitt JC, Steinberg G, Locke T, et al. Using a claims data-based sentinel system to improve compliance with clinical guidelines: re…
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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/60168/psn-pdf
March 25, 2020 - Right Electrocardiogram, Wrong Patient
March 25, 2020
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
The Cases
Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…
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psnet.ahrq.gov/node/49841/psn-pdf
September 01, 2018 - to promote transparency and safe ordering practices despite the multiple advantages
provided by EHR capabilities
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psnet.ahrq.gov/issue/effect-facility-complexity-perceptions-safety-climate-operating-room-size-matters
December 21, 2014 - Study
The effect of facility complexity on perceptions of safety climate in the operating room: size matters.
Citation Text:
Carney BT, West P, Neily J, et al. The effect of facility complexity on perceptions of safety climate in the operating room: size matters. Am J Med Qual. 2010;25…