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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
October 01, 2010 - Spotlight Case July 2008
Spotlight Case October 2010
Dangerous Dialysis
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Source and Credits
This presentation is based on the October 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…
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psnet.ahrq.gov/issue/resilient-health-care-society
October 09, 2019 - Multi-use Website
Resilient Health Care Society.
Citation Text:
Resilient Health Care Society. Sweden.
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Novem…
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psnet.ahrq.gov/node/37792/psn-pdf
February 15, 2011 - Exploring organizational context and structure as
predictors of medication errors and patient falls.
February 15, 2011
Mark BA, Hughes LC, Belyea M, et al. Exploring Organizational Context and Structure as Predictors of
Medication Errors and Patient Falls. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e3181695671.…
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psnet.ahrq.gov/node/37227/psn-pdf
December 15, 2011 - Intensive care unit safety incidents for medical versus
surgical patients: a prospective multicenter study.
December 15, 2011
Sinopoli DJ, Needham DM, Thompson DA, et al. Intensive care unit safety incidents for medical versus
surgical patients: a prospective multicenter study. J Crit Care. 2007;22(3):177-83.
http…
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psnet.ahrq.gov/node/860049/psn-pdf
January 04, 2024 - Myasthenia Crisis after a Delayed Diagnosis in a
Medically Complex Patient.
January 4, 2024
Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. PSNet [internet].
2024.
https://psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
The Case
A 9…
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psnet.ahrq.gov/node/39063/psn-pdf
December 17, 2009 - Safety and risk management interventions in hospitals: a
systematic review of the literature.
December 17, 2009
Dückers M, Faber M, Cruijsberg J, et al. Safety and risk management interventions in hospitals: a
systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):90S-119S.
doi:10.1177/10775587093…
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - SNFs: Opening the Black Box
December 1, 2013
Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/snfs-opening-black-box
The Case
An 88-year-old woman was admitted to a skilled nursing facility (SNF) after a lengthy hospitalization for a
small bowel obstructio…
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psnet.ahrq.gov/issue/minnesota-alliance-patient-safety-maps
October 31, 2023 - Multi-use Website
Minnesota Alliance for Patient Safety (MAPS).
Citation Text:
Minnesota Alliance for Patient Safety (MAPS). Minnesota Hospital and Healthcare Partnership.
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psnet.ahrq.gov/node/43280/psn-pdf
November 30, 2016 - Medical Office Survey on Patient Safety Culture: 2014
User Comparative Database Report.
November 30, 2016
Sorra J, Famolaro T, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; June
2014. Report No. 14-0032-EF.
https://psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture-2014…
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psnet.ahrq.gov/node/42748/psn-pdf
November 20, 2013 - Effectiveness of written hospitalist sign-outs in answering
overnight inquiries.
November 20, 2013
Fogerty RL, Schoenfeld A, Al-Damluji MS, et al. Effectiveness of written hospitalist sign-outs in answering
overnight inquiries. J Hosp Med. 2013;8(11):609-14. doi:10.1002/jhm.2090.
https://psnet.ahrq.gov/issue/effec…
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psnet.ahrq.gov/node/39213/psn-pdf
October 03, 2017 - Using patient safety morbidity and mortality conferences
to promote transparency and a culture of safety.
October 3, 2017
Szekendi MK, Barnard C, Creamer J, et al. Using patient safety morbidity and mortality conferences to
promote transparency and a culture of safety. Jt Comm J Qual Patient Saf. 2010;36(1):3-9.
h…
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psnet.ahrq.gov/node/38449/psn-pdf
March 04, 2009 - A model for increasing patient safety in the intensive care
unit: increasing the implementation rates of proven safety
measures.
March 4, 2009
Krimsky WS, Mroz IB, McIlwaine JK, et al. A model for increasing patient safety in the intensive care unit:
increasing the implementation rates of proven safety measures. Q…
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psnet.ahrq.gov/node/50754/psn-pdf
December 18, 2019 - California.15 Both organizations offer
videos or short informational brochures with low-health-literacy descriptions
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psnet.ahrq.gov/node/41257/psn-pdf
April 22, 2012 - Development of an evidence-based framework of factors
contributing to patient safety incidents in hospital
settings: a systematic review.
April 22, 2012
Lawton R, McEachan RRC, Giles SJ, et al. Development of an evidence-based framework of factors
contributing to patient safety incidents in hospital settings: a sy…
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psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
April 04, 2018 - Informed consent and a treatment agreement can be essential and should include clear descriptions of
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psnet.ahrq.gov/node/45293/psn-pdf
February 01, 2017 - Patient safety incidents involving sick children in primary
care in England and Wales: a mixed methods analysis.
February 1, 2017
Rees P, Edwards A, Powell C, et al. Patient Safety Incidents Involving Sick Children in Primary Care in
England and Wales: A Mixed Methods Analysis. PLoS Med. 2017;14(1):e1002217.
doi:1…
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psnet.ahrq.gov/issue/when-surgery-goes-wrong-weighing-risks
December 18, 2019 - Newspaper/Magazine Article
When surgery goes wrong: weighing up the risks.
Citation Text:
When surgery goes wrong: weighing up the risks. Feinmann J. The Independent. November 14, 2006.
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psnet.ahrq.gov/issue/safety-anaesthesia
April 07, 2021 - Special or Theme Issue
Safety in Anaesthesia.
Citation Text:
Safety in Anaesthesia. Staender S, ed. Best Pract Res Clin Anaesthesiol. 2011;25(2):109-304.
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psnet.ahrq.gov/issue/solving-puzzle-improving-safety-outcomes
September 07, 2022 - Commentary
Solving the puzzle: improving safety outcomes.
Citation Text:
Solving the puzzle: improving safety outcomes. Whitehouse D. Br J Healthc Manage. 2013;19(9):446-448.
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psnet.ahrq.gov/issue/seeing-through-google-glass-using-innovative-technology-improve-medication-safety-behaviors
September 15, 2021 - Study
Seeing through Google Glass: using an innovative technology to improve medication safety behaviors in undergraduate nursing students.
Citation Text:
Schneidereith T. Seeing Through Google Glass: Using an Innovative Technology to Improve Medication Safety Behaviors in Undergraduate …