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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39672/psn-pdf
    December 17, 2010 - prevalence-and-predictors-adverse-events-older-surgical-patients-impact-present-admission https://psnet.ahrq.gov/issue/medicares-decision-withhold-payment-hospital-errors-devil-details
  2. psnet.ahrq.gov/issue/how-can-health-care-organizations-become-more-health-literate-workshop-summary
    October 08, 2014 - This report details the results of a workshop on health literacy in health care organizations.
  3. psnet.ahrq.gov/issue/acting-concerns-your-professional-responsibility
    April 02, 2014 - This report details how clinicians can speak up and discuss concerns that may affect safety in surgical
  4. psnet.ahrq.gov/issue/lessons-americas-safest-hospitals
    November 16, 2016 - This magazine article details how several hospitals have taken a comprehensive approach to improving
  5. psnet.ahrq.gov/issue/doctors-use-more-devices-potential-distraction-grows
    March 06, 2005 - widespread use of mobile devices (such as iPads and smartphones) in health care, this newspaper article details
  6. psnet.ahrq.gov/issue/computerized-medication-order-errors-studied
    March 26, 2014 - This news article details how research on errors related to computerized provider order entry may help
  7. psnet.ahrq.gov/issue/medical-mistakes-no-longer-billable-bold-steps-taken-state-reduce-hospital-errors
    August 06, 2008 - not reimburse hospitals for care related to 28 preventable errors , though they have not specified details
  8. psnet.ahrq.gov/issue/nurse-physician-communications-connecting-safety
    July 29, 2009 - Exploring communication gaps and errors between nurses and physicians , this article details how safety
  9. psnet.ahrq.gov/issue/preventing-wrong-site-surgery-minnesota-5-year-journey
    December 19, 2007 - Discussing a 5-year effort to report , analyze, and reduce wrong-site procedures , this magazine article details
  10. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
    January 01, 2020 - diabetes technology may have contributed to avoidable hyperglycemia after acute stroke 4 Case Details … numbness – Head CT was normal – Transferred to academic medical center for further management 5 Case Details … high dose steroids and three rounds of plasmapheresis • Discharged home three weeks later 6 Case Details
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44949/psn-pdf
    February 01, 2019 - Please refer to the information link below for further details.
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44688/psn-pdf
    February 23, 2018 - Summarizing the goals from the report, this commentary details how the recommendations from the NAM
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41132/psn-pdf
    March 13, 2012 - The article details how stratiegies for communication, local adaptation, teamwork, and learning from
  14. psnet.ahrq.gov/issue/medication-management-detailed-use-case
    June 29, 2016 - Book/Report Medication Management: Detailed Use Case. Citation Text: Medication Management: Detailed Use Case. Washington, DC: Office of the National Coordinator for Health Information Technology, US Department of Health and Human Services; 2007. Copy Citation Sav…
  15. psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
    January 01, 2025 - abdominal pain, and how to mitigate the influence of cognitive biases in the diagnostic process. 4 Case Details … Case Details The physical exam was notable for guarding and a small periumbilical knot, which was not … Case Details While awaiting test results, the ED physician ordered a “GI cocktail,” which provided no … Case Details The following day, the patient’s wife took him to another ED with similar symptoms, but … Case Details Laboratory test results were also similar except that the hemoglobin was even higher as
  16. psnet.ahrq.gov/glossary/handoffs-and-handovers
    September 13, 2021 - The summary may leave out key details due to oversight, exacerbated by an unstructured process and being
  17. psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
    January 01, 2020 - A case describing how care inconsistent with patient goals can lead to preventable harm 4 Case Details … he continued to require intermittent high flow oxygen or BIPAP to maintain oxygenation 5 Case Details … and discharge planner worked with social services agency to coordinate the transfer home 6 Case Details … status and plan for home hospice care and felt no further interventions would be required 7 Case Details
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841139/psn-pdf
    December 14, 2022 - For this reason, the responsibility of obtaining such details falls on both the surgical and anesthesia … The details of the case should be recorded online so that this information can be accessed by future … Difficult Airway.”17 The patient sometimes only remembers that there was a problem but does not recall the details … Giving the patient a card with the access details for the online difficult airway registry and a MedicAlert
  19. psnet.ahrq.gov/issue/reduce-readmissions-pharmacy-programs-focus-transitions-hospital-community
    September 26, 2016 - This article details how a community liaison pharmacist who works with clinicians in hospitals can help
  20. psnet.ahrq.gov/issue/cardiac-arrest-during-anesthesia
    January 19, 2011 - This article reviews factors contributing to anesthesia-related cardiac arrests and details prevention

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