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psnet.ahrq.gov/node/49768/psn-pdf
September 01, 2016 - A Pill Organizing Plight
September 1, 2016
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/pill-organizing-plight
Case Objectives
Identify patients at high risk for adverse drug events.
List drugs that are considered inappropriate in older patients.
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - SPOTLIGHT CASE
Too Many Cooks in the Kitchen
Citation Text:
Dutton RP. Too Many Cooks in the Kitchen. 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/web-mm/pill-organizing-plight
June 19, 2018 - SPOTLIGHT CASE
A Pill Organizing Plight
Citation Text:
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
August 14, 2024 - SPOTLIGHT CASE
Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.
Citation Text:
Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…
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psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
June 09, 2021 - Book/Report
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.
Citation Text:
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
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psnet.ahrq.gov/issue/prioritizing-patient-safety-through-quality-measurement
November 14, 2011 - Webinar
Prioritizing Patient Safety Through Quality Measurement.
Citation Text:
Prioritizing Patient Safety Through Quality Measurement. Centers for Medicare & Medicaid Services, March 6 and 21, 2024.
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psnet.ahrq.gov/issue/dod-should-improve-its-process-clinical-adverse-actions-against-providers
May 16, 2018 - Book/Report
DOD Should Improve Its Process for Clinical Adverse Actions against Providers.
Citation Text:
DOD Should Improve Its Process for Clinical Adverse Actions against Providers. Washington, DC: United States Government Accounting Office; April 11, 2024. Publication GAO-24-106107.
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psnet.ahrq.gov/issue/physician-burnout
May 01, 2017 - Book/Report
Physician Burnout.
Citation Text:
Physician Burnout. Rockville, MD: Agency for Healthcare Research and Quality; July 2017. AHRQ Publication No. 17-M018-1-EF.
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psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors
February 17, 2017 - Newspaper/Magazine Article
Could it happen here? Learning from other organizations' safety errors.
Citation Text:
Conway JB. Could it happen here? Learning from other organizations' safety errors. Healthcare Executive. 2008;23(6):64, 66-67.
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psnet.ahrq.gov/issue/acog-committee-opinion-590-preparing-clinical-emergencies-obstetrics-and-gynecology
May 22, 2019 - Commentary
ACOG Committee Opinion #590: preparing for clinical emergencies in obstetrics and gynecology.
Citation Text:
Improvement AC of O and GC on PS and Q. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014;123(3):722-5. d…
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psnet.ahrq.gov/issue/acog-committee-opinion-546-tracking-and-reminder-systems
May 22, 2019 - Commentary
ACOG Committee Opinion #546: tracking and reminder systems.
Citation Text:
Improvement AC of O and GC on PS and Q. Committee Opinion No.546: Tracking and reminder systems. Obstet Gynecol. 2012;120(6):1535-7. doi:10.1097/01.AOG.0000423820.92906.d0.
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psnet.ahrq.gov/issue/hidden-danger-obvious-opportunity-error-and-risk-management-cancer
June 07, 2018 - Commentary
Hidden danger, obvious opportunity: error and risk in the management of cancer.
Citation Text:
Munro AJ. Hidden danger, obvious opportunity: error and risk in the management of cancer. Br J Radiol. 2007;80(960):955-66.
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psnet.ahrq.gov/issue/diagnostic-centers-excellence-partnerships-improve-diagnostic-safety-and-quality-r18
March 08, 2023 - Grant Announcement
Diagnostic Centers of Excellence: Partnerships to Improve Diagnostic Safety and Quality (R18).
Citation Text:
Diagnostic Centers of Excellence: Partnerships to Improve Diagnostic Safety and Quality (R18). Rockville, MD: Agency for Healthcare Research and Quality; April…
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psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient
June 10, 2018 - Newspaper/Magazine Article
Multiple latent failures align to allow a serious drug interaction to harm a patient.
Citation Text:
Multiple latent failures align to allow a serious drug interaction to harm a patient. ISMP Medication Safety Alert! Acute care edition. May 5, 2011;16:1-3.
Co…
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psnet.ahrq.gov/issue/strategies-improve-patient-safety-final-report-congress-required-patient-safety-and-quality
June 21, 2016 - Book/Report
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.
Citation Text:
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.…
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psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review
June 19, 2019 - Review
Organizational learning in hospitals: a realist review.
Citation Text:
Lyman B, Jacobs JD, Hammond EL, et al. Organizational learning in hospitals: A realist review. J Adv Nurs. 2019;75(11):2352-2377. doi:10.1111/jan.14091.
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psnet.ahrq.gov/issue/pridx-framework-engage-payers-reducing-diagnostic-errors-healthcare
January 22, 2025 - Commentary
The PRIDx framework to engage payers in reducing diagnostic errors in healthcare.
Citation Text:
Ali KJ, Goeschel CA, DeLia DM, et al. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare. Diagnosis (Berl). 2024;11(1):17-24. doi:10.1515/dx-2023-0042…
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psnet.ahrq.gov/issue/twelve-tips-engaging-learners-checking-health-care-decisions
February 27, 2014 - Commentary
Twelve tips on engaging learners in checking health care decisions.
Citation Text:
Sibbald M, de Bruin A, van Merrienboer JJG. Twelve tips on engaging learners in checking health care decisions. Med Teach. 2014;36(2):111-5. doi:10.3109/0142159X.2013.847910.
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psnet.ahrq.gov/issue/documenting-day-discussion-ahead-crest-wave-creating-national-agenda-systemic-change-enhanced
April 28, 2021 - Book/Report
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change for Enhanced Clinician Well-Being.
Citation Text:
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change …
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psnet.ahrq.gov/issue/patient-safety-education-what-was-what-and-what-will-be
April 10, 2019 - Commentary
Patient safety education: what was, what is, and what will be?
Citation Text:
Klamen D, Sanserino K, Skolnik PJ. Patient Safety Education: What Was, What Is, and What Will Be? Teach Learn Med. 2013;25(sup1). doi:10.1080/10401334.2013.842906.
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