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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - Long-Term Care Standards Manual (1996), Standards RI.2.6 (defining restraint), TX.8
(emphasizing a restraint-free
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - Long-Term Care Standards Manual (1996), Standards RI.2.6 (defining restraint), TX.8 (emphasizing a restraint-free
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - June 26, 2019
Drawing boundaries: the difficulty in defining clinical reasoning.
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - In addition to hiring and training staff dedicated to performing BPMH, the MARQUIS study showed that defining
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psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - April 3, 2024
Defining the landscape of patient harm after osteopathic manipulative treatment
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - SPOTLIGHT CASE
A Fatal Twist in Pseudohyperkalemia
Citation Text:
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/issue/improving-process-while-changing-practice-fmea-and-medication-administration
January 18, 2011 - Commentary
Improving process while changing practice: FMEA and medication administration.
Citation Text:
Riehle MA, Bergeron D, Hyrkäs K. Improving process while changing practice. Nurs Manage. 2009;39(2). doi:10.1097/01.numa.0000310533.54708.38.
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psnet.ahrq.gov/issue/improving-safety-throughout-medication-use-process-neonatal-intensive-care-unit
January 27, 2012 - Commentary
Improving safety throughout the medication use process in a neonatal intensive care unit.
Citation Text:
Asdigha MN. Improving Safety Throughout the Medication Use Process in a Neonatal Intensive Care Unit. Hosp Pharm. 2010;41(11):1067-1075. doi:10.1310/hpj4111-1067.
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psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
March 23, 2012 - Book/Report
Classic
Serious Reportable Events in Healthcare—2011 Update.
Citation Text:
Serious Reportable Events in Healthcare—2011 Update. Washington DC: National Quality Forum; December 2011.
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psnet.ahrq.gov/issue/prescription-drug-monitoring-programs-evidence-based-practices-optimize-prescriber-use
September 19, 2018 - Book/Report
Prescription Drug Monitoring Programs: Evidence-based Practices to Optimize Prescriber Use.
Citation Text:
Prescription Drug Monitoring Programs: Evidence-based Practices to Optimize Prescriber Use. Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, …
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psnet.ahrq.gov/issue/creating-culture-safety-coaching-clinicians-competence
January 10, 2024 - Commentary
Creating a culture of safety by coaching clinicians to competence.
Citation Text:
Duff B. Creating a culture of safety by coaching clinicians to competence. Nurse Educ Today. 2013;33(10):1108-11. doi:10.1016/j.nedt.2012.05.025.
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psnet.ahrq.gov/issue/systematic-review-evidence-publishing-patient-care-performance-data-improves-quality-care
September 06, 2017 - Review
Systematic review: the evidence that publishing patient care performance data improves quality of care.
Citation Text:
Fung CH, Lim Y-W, Mattke S, et al. Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med. 2008;…
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psnet.ahrq.gov/issue/improving-patient-care-my-right-knee
August 04, 2021 - Commentary
Improving patient care. My right knee.
Citation Text:
Berwick DM. Improving patient care. My right knee. Ann Intern Med. 2005;142(2):121-5.
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psnet.ahrq.gov/issue/enhancing-culture-safety-through-disclosure-adverse-events
October 26, 2022 - Newspaper/Magazine Article
Enhancing a culture of safety through disclosure of adverse events.
Citation Text:
Enhancing a culture of safety through disclosure of adverse events. Cornelissen C, Call RC, Harbell MW, et al. APSF Newsletter. February 202136(1);25-27
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psnet.ahrq.gov/issue/nurses-perceptions-multidisciplinary-team-work-acute-health-care
January 06, 2017 - Image/Poster
Nurses' perceptions of multidisciplinary team work in acute health-care.
Citation Text:
Atwal A, Caldwell K. Nurses' perceptions of multidisciplinary team work in acute health-care. Int J Nurs Pract. 2006;12(6):359-65.
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psnet.ahrq.gov/issue/workplace-bullying-or-results-descriptive-study
December 21, 2017 - Study
Workplace bullying in the OR: results of a descriptive study.
Citation Text:
Chipps E, Stelmaschuk S, Albert NM, et al. Workplace Bullying in the OR: Results of a Descriptive Study. AORN J. 2013;98(5). doi:10.1016/j.aorn.2013.08.015.
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psnet.ahrq.gov/issue/misunderstanding-safety-culture-and-its-relationship-safety-management
May 10, 2014 - Commentary
(Mis)understanding safety culture and its relationship to safety management.
Citation Text:
Guldenmund FW. (Mis)understanding Safety Culture and Its Relationship to Safety Management. Risk Anal. 2010;30(10):1466-80. doi:10.1111/j.1539-6924.2010.01452.x.
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psnet.ahrq.gov/issue/guideline-prevention-unintentionally-retained-surgical-items
August 01, 2018 - Commentary
Guideline for Prevention of Unintentionally Retained Surgical Items.
Citation Text:
Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6. doi:10.1002/aorn.13579.
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psnet.ahrq.gov/issue/measuring-hospital-wide-activity-volume-patient-safety-and-infection-control-multi-centre
January 15, 2009 - Study
Measuring hospital-wide activity volume for patient safety and infection control: a multi-centre study in Japan.
Citation Text:
Hayashida K, Imanaka Y, Fukuda H. Measuring hospital-wide activity volume for patient safety and infection control: a multi-centre study in Japan. BMC H…