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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - SPOTLIGHT CASE
An Inadvertent Bolus of Norepinephrine.
Citation Text:
Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
August 01, 2006 - availability of data (both qualitative and quantitative) that identified many of the problems, appropriate consideration
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005
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Citation Text:
Conway JB, Weingart SN. Organizational Change…
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psnet.ahrq.gov/node/33564/psn-pdf
March 15, 2025 - Computerized Provider Order Entry
March 15, 2025
Computerized Provider Order Entry. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/computerized-provider-order-entry
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice…
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psnet.ahrq.gov/primer/computerized-provider-order-entry
March 15, 2025 - Computerized Provider Order Entry
Citation Text:
Computerized Provider Order Entry. 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/curated-article-libraries
March 18, 2025 - Curated Libraries
Curated Libraries are groupings of PSNet content, curated by AHRQ and by other experts in the patient safety field.
Watch the video to learn more about how this new feature works and how it can be of benefit to you.
Latest PSNet…
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psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
April 01, 2008 - Annual Perspective
Measuring and Responding to Deaths From Medical Errors
Sumant Ranji, MD | March 22, 2016
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Citation Text:
Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. Rockville…
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psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
June 14, 2023 - He should have been admitted to the ICU for IV benzodiazepines with consideration of adjunctive dexmedetomidine
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - Health Care Data Science for Quality Improvement and Patient Safety
Alvin Rajkomar, MD | October 1, 2016
Also Read a Conversation
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Citation Text:
Rajkomar A. Health Care Data Science for Quality Improvement and Patient S…
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psnet.ahrq.gov/perspective/covid-19-and-built-environment
June 30, 2021 - Given that new consideration, waiting rooms as designed prior to the pandemic were poorly suited to ensure
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psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - availability of data (both qualitative and quantitative) that identified many of the problems, appropriate consideration
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psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
…
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles
Citation Text:
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. 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/perspective/balancing-supervision-and-autonomy-ongoing-tension
February 01, 2012 - However, educators must also take into consideration the safety of the trainee's future patients.
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psnet.ahrq.gov/perspective/what-makes-good-checklist
October 01, 2010 - Consideration of physical demands is extremely important—for example, if hand hygiene is necessary, a
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - Consideration of physical demands is extremely important—for example, if hand hygiene is necessary, a
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psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP
November 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience
William S. Krimsky, MD | November 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [inter…
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psnet.ahrq.gov/web-mm/magnetic-deflection
November 18, 2016 - The Magnetic Deflection
Citation Text:
Kanal E. The Magnetic Deflection. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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