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psnet.ahrq.gov/node/49669/psn-pdf
November 01, 2012 - Transfusion Overload
November 1, 2012
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfusion-overload
Case Objectives
Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit
below 30% are not supported by the evidence.…
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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - Near Miss with Bedside Medications
November 1, 2011
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications
Case Objectives
Understanding the definition of near miss—also known as close call.
Appreciate the importance of close calls in reducin…
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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - Delayed Diagnosis and Treatment of an Occult
Hemothorax Following Complicated Central Line Insertion
Leads to Cardiac Arrest
January 26, 2022
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated
Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022.
https…
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psnet.ahrq.gov/node/33738/psn-pdf
December 01, 2012 - In Conversation With... John G. Reiling, PhD
December 1, 2012
In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
Editor's note: John G. Reiling, PhD, is president and CEO of Safe by Design. Dr. Reiling consults with
hospitals and…
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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - Check the Wristband
July 1, 2003
Rosenthal M. Check the Wristband. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/check-wristband
The Case
The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the
impending surgery. The patient spoke English and appeared to be of aver…
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - In Conversation With… Andrew Gettinger, MD
September 1, 2017
In Conversation With… Andrew Gettinger, MD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
Editor's note: Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the
Office of Cli…
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psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
March 01, 2006 - Hyperbilirubinemia Refractory to Phototherapy
Citation Text:
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic
Save
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April 27, 2022
Innovation
Conta…
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psnet.ahrq.gov/issue/adverse-drug-events-caused-serious-medication-administration-errors
December 19, 2009 - Study
Adverse drug events caused by serious medication administration errors.
Citation Text:
Kale A, Keohane C, Maviglia SM, et al. Adverse drug events caused by serious medication administration errors. BMJ Qual Saf. 2012;21(11):933-8. doi:10.1136/bmjqs-2012-000946.
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…
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psnet.ahrq.gov/node/36869/psn-pdf
August 31, 2011 - An extra dose of safety.
August 31, 2011
An extra dose of safety. Installation of a bar-coding system drives an entire workflow redesign at a non-
profit hospital and healthcare network. Health management technology. 2007;28(4):30-2, 34.
https://psnet.ahrq.gov/issue/extra-dose-safety
This article describes a healt…
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psnet.ahrq.gov/issue/medical-team-training-and-coaching-veterans-health-administration-assessment-and-impact-first
December 21, 2014 - Study
Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.
Citation Text:
Neily J, Mills PD, Lee P, et al. Medical team training and coaching in the Veterans Health Administration; assessment and im…
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psnet.ahrq.gov/node/42131/psn-pdf
March 20, 2013 - What surgeons leave behind costs some patients dearly.
March 20, 2013
Eisler P.
https://psnet.ahrq.gov/issue/what-surgeons-leave-behind-costs-some-patients-dearly
This newspaper article describes two incidents of retained surgical items and discusses the technological
solutions to prevent them.
https://psnet.ahrq…
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psnet.ahrq.gov/node/39804/psn-pdf
October 13, 2010 - Patient misidentifications caused by errors in standard
barcode technology.
October 13, 2010
Snyder ML, Carter A, Jenkins K, et al. Patient misidentifications caused by errors in standard bar code
technology. Clin Chem. 2010;56(10):1554-60. doi:10.1373/clinchem.2010.150094.
https://psnet.ahrq.gov/issue/patient-mis…
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psnet.ahrq.gov/issue/teamwork-and-communication
February 06, 2019 - Special or Theme Issue
Teamwork and Communication.
Citation Text:
Teamwork and Communication. Pa Patient Saf Advis. June 2010;7(suppl 2):1-16.
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Linke…
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psnet.ahrq.gov/node/44298/psn-pdf
July 08, 2015 - Preparing challenging medications for barcode scanning.
July 8, 2015
Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm.
2015;72(13):1089-90. doi:10.2146/ajhp140454.
https://psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning
Barcode scanning can reduce me…
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psnet.ahrq.gov/node/39897/psn-pdf
September 26, 2016 - Nurse interruptions pre- and post-implementation of a
point-of-care medication administration system.
September 26, 2016
Stamp KD, Willis DG. Nurse interruptions pre- and postimplementation of a point-of-care medication
administration system. J Nurs Care Qual. 2010;25(3):231-239. doi:10.1097/NCQ.0b013e3181d4a13f.
…
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psnet.ahrq.gov/node/38659/psn-pdf
May 27, 2009 - The Henry Ford Production System: reduction of surgical
pathology in-process misidentification defects by bar
code-specified work process standardization.
May 27, 2009
Zarbo RJ, Tuthill M, D'Angelo R, et al. The Henry Ford Production System: reduction of surgical pathology
in-process misidentification defects by b…
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psnet.ahrq.gov/node/40790/psn-pdf
January 01, 2012 - Nurses' perceptions of simulation-based interprofessional
training program for rapid response and code blue
events.
December 1, 2011
Wehbe-Janek H, Lenzmeier CR, Ogden PE, et al. Nurses' perceptions of simulation-based
interprofessional training program for rapid response and code blue events. J Nurs Care Qual.
2…
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psnet.ahrq.gov/node/44838/psn-pdf
February 10, 2016 - ADVERSE drug events: incidence and risk reduction
across the care continuum.
February 10, 2016
Wanderer JP, Rathmell JP. ADVERSE Drug Events: Incidence & risk reduction across the care continuum.
Anesthesiology. 2016;124(1):A23. doi:10.1097/01.anes.0000473722.20007.03.
https://psnet.ahrq.gov/issue/adverse-drug-eve…
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psnet.ahrq.gov/web-mm/citrate-mix
February 01, 2010 - Citrate Mix-Up
Citation Text:
Weber RJ. Citrate Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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…