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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865656/psn-pdf
    April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous Combination April 24, 2024 Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination The Case A 26-ye…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49865/psn-pdf
    June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy June 1, 2019 Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy The Case A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
  3. psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
    February 26, 2025 - In Conversation With… Ann L. Hendrich, RN, PhD December 1, 2011  Citation Text: In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Cita…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853773/psn-pdf
    September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72811/psn-pdf
    September 01, 2022 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors Originally published on March 3, 2021 Last updated on March 16, 2021 https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during- initial-treatment Summar…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33885/psn-pdf
    August 01, 2019 - In Conversation With… Susan Smith, MD August 1, 2019 In Conversation With… Susan Smith, MD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-susan-smith-md Editor's note: Dr. Smith, a family medicine physician, is chief faculty practices officer for UCSF Health. Over the past 3–4 years, the …
  8. www.ahrq.gov/sites/default/files/publications2/files/dx-issue-brief-20-brazil-health-system.pdf
    August 01, 2024 - Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study PATIENT SAFETY e Issue Brief 20 Learning from AHRQs’ Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study This page intentionally left blank. e Issue Brief 2…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865376/psn-pdf
    March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures March 27, 2024 Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
  10. psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
    September 30, 2011 - Safeguarding Diagnostic Testing at the Point of Care Citation Text: Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: …
  11. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module6/sustainability-slides-spanish.pptx
    January 01, 2005 - Módulo 6: Sostenibilidad Módulo 6: Sostenibilidad Programa de seguridad de la AHRQ para cuidados a largo plazo: HAI/CAUTI Kit de herramientas de seguridad para cuidados a largo plazo AHRQ Pub. No. 16(17)-0003-03-EF Marzo de 2017 Sostenibilidad | ‹#› 1 Objetivos Definir la sostenibilidad y comprender la importanc…
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/mindfulness-061014.pptx
    March 07, 2014 - The Integration of Hospitalists into U.S. Academic Medical Centers Mindfulness: Engaging Frontline Providers in Antimicrobial Stewardship 1 CAPT Arjun Srinivasan, MD Associate Director for Healthcare Associated Infection Prevention Programs Division of Healthcare Quality Promotion Scott Flanders, MD Professor of Med…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49864/psn-pdf
    June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 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]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
  14. www.ahrq.gov/sites/default/files/2024-01/grahamlear-report.pdf
    January 01, 2024 - Final Progress Report: Improving Quality in Medication Management in Schools Project Title: Improving Quality in Medication Management in Schools Principal Investigator: Julia Graham Lear, PhD Team Members: Annette Ferebee, MPH, Project Director Nancy Eichner, MUP, Senior Program Manager Theresa Chapman, Executive …
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49549/psn-pdf
    December 06, 2007 - Elopement December 1, 2007 Gerardi D. Elopement. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/elopement Case Objectives Define elopement and differentiate it from wandering and leaving against medical advice. Identify leading contributors to elopement events. Describe strategies for preventing elopement…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33654/psn-pdf
    August 01, 2007 - In Conversation with...James L. Reinertsen, MD August 1, 2007 In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting firm …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49508/psn-pdf
    January 01, 2007 - Language Barrier April 1, 2006 Flores G. Language Barrier. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/language-barrier The Case A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish- speaking parents when they noted that their daughter had generalized we…
  19. www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/3-sorra-sops-hospital-survey-2-0-webcast.pdf
    July 20, 2020 - AHRQ Webcast Introducing the New SOPS Hospital Survey 2.0 - Sorra AHRQ Surveys on Patient Safety Culture™ Hospital Survey Version 2.0 Joann Sorra, PhD Project Director, AHRQ Surveys on Patient Safety Culture User Network, Westat 12 HSOPS 2.0 Development Team • Westat Research Team: Theresa Famolaro, MPS, MS, …
  20. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-event-reporting-revised.docx
    April 01, 2022 - CLABSI Event Reporting Tool CAUTI Event Report Tool: Data for Event Analysis This event report tool is designed to be used as a guide through the initial investigation for a defect analysis where the primary goal is to learn what happened and what factors may have contributed to the catheter-associated urinary trac…