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psnet.ahrq.gov/node/33807/psn-pdf
May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD
May 1, 2016
In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
Editor's note: Dr. Drew, a nurse researcher, is the David Mortara Distinguished Professor of Physiological
Nursing and…
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psnet.ahrq.gov/node/49400/psn-pdf
May 01, 2003 - Central Line Clot
May 1, 2003
Randolph AG. Central Line Clot. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/central-line-clot
Case Objectives
List the complications of central line manipulation
Appreciate the limitations of diagnostic studies for PE in children
Describe modalities for prevention of cathe…
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - Spinal Epidural Abscess
Citation Text:
Lu Y, Salvador D. Spinal Epidural Abscess. 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/847934/psn-pdf
April 26, 2023 - Patient Safety Indicators
April 26, 2023
Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/patient-safety-indicators
Background
Over the past 25 years, policymakers and providers, payers, and purchasers of health care have
increasingly focused attention on pati…
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - SPOTLIGHT CASE
When the Indications for Drug Administration Blur
Citation Text:
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
Citation Text:
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
November 13, 2024 - The Second Victim Phenomenon: A Harsh Reality of Health Care Professions
Susan D. Scott RN, MSN | May 1, 2011
View more articles from the same authors.
Citation Text:
Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [intern…
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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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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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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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