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psnet.ahrq.gov/web-mm/discharging-our-responsibility
January 16, 2019 - as conforming to the performance measure, hospitals are required to provide instructions in all six domains … According to the Joint Commission and Medicare, providing HF education in six key domains at discharge
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - In other domains where prediction is applied—like which movie or product you may enjoy—the consequences
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psnet.ahrq.gov/node/40473/psn-pdf
July 02, 2011 - A systematic review of failures in handoff communication
during intrahospital transfers.
July 2, 2011
Ong M-S, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers.
Jt Comm J Qual Patient Saf. 2011;37(6):274-284.
https://psnet.ahrq.gov/issue/systematic-review-failures-h…
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psnet.ahrq.gov/issue/mental-health-inpatient-settings-creating-conditions-delivery-safe-and-therapeutic-care
November 20, 2024 - Book/Report
Mental Health Inpatient Settings: Creating Conditions for the Delivery of Safe and Therapeutic Care to Adults.
Citation Text:
Mental Health Inpatient Settings: Creating Conditions For The Delivery Of Safe And Therapeutic Care To Adults. Health Services Safety Investigations B…
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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - Failure to Report
March 1, 2007
Spath P. Failure to Report. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/failure-report
Case Objectives
List common causes of medical errors.
Appreciate the magnitude of underreporting of adverse events.
List the common barriers to reporting adverse events and near misses…
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psnet.ahrq.gov/node/39489/psn-pdf
June 11, 2010 - What happens between visits? Adverse and potential
adverse events among a low-income, urban, ambulatory
population with diabetes.
June 11, 2010
Sarkar U, Handley MA, Gupta R, et al. What happens between visits? Adverse and potential adverse
events among a low-income, urban, ambulatory population with diabetes. Qua…
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psnet.ahrq.gov/node/41941/psn-pdf
February 11, 2013 - A cross-sectional study on the relationship between
utilization of root cause analysis and patient safety at 139
Department of Veterans Affairs medical centers.
February 11, 2013
Percarpio KB, Watts V. A cross-sectional study on the relationship between utilization of root cause
analysis and patient safety at 139 …
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psnet.ahrq.gov/web-mm/returning-home-safely
December 22, 2018 - template that (i) embeds transition planning into the SNF's routines of care and (ii) delineates the domains
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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - landmark study using a systems analysis of adverse drug events, Leape and
colleagues identified several domains … These domains included lack
of information about the patient, drug stocking and delivery problems, and
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psnet.ahrq.gov/node/49707/psn-pdf
April 01, 2014 - CYP450 Drugs: Expect the Unexpected
April 1, 2014
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
The Case
A 42-year-old man with acquired immunodeficiency syndrome (AIDS) (CD4 count 198), hip dystocia, and
generalized anxiety …
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psnet.ahrq.gov/issue/lurking-danger-business-case-patient-safety
May 13, 2020 - Commentary
The lurking danger in the “business case” for patient safety
Citation Text:
The lurking danger in the “business case” for patient safety Millenson ML. Health Affairs Blog. December 2, 2019.
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psnet.ahrq.gov/issue/hospital-medication-errors-commonplace
August 02, 2023 - Audiovisual
Hospital Medication Errors Commonplace.
Citation Text:
Hospital Medication Errors Commonplace. Berwick D; Lassman S; Bates D. National Public Radio. July 28, 2006.
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…
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psnet.ahrq.gov/issue/quality-improvement-and-patient-safety-competencies-across-learning-continuum
November 06, 2019 - Book/Report
Quality Improvement and Patient Safety Competencies Across the Learning Continuum.
Citation Text:
Quality Improvement and Patient Safety Competencies Across the Learning Continuum. AAMC New and Emerging Areas in Medicine Series. Washington, DC: Association of American Medical…
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psnet.ahrq.gov/issue/sources-power-how-people-make-decisions
November 19, 2015 - Book/Report
Classic
Sources of Power: How People Make Decisions.
Citation Text:
Sources of Power: How People Make Decisions. Klein G. Cambridge MA: Massachusetts Institute of Technology; 1999. ISBN: 9780262611466.
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psnet.ahrq.gov/issue/who-draft-guidelines-adverse-event-reporting-and-learning-systems
October 21, 2010 - Organizational Policy/Guidelines
WHO Draft Guidelines for Adverse Event Reporting and Learning Systems.
Citation Text:
WHO Draft Guidelines for Adverse Event Reporting and Learning Systems. World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2005.
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psnet.ahrq.gov/issue/50-years-inquiries-national-health-service
March 02, 2010 - Special or Theme Issue
50 Years of Inquiries in the National Health Service.
Citation Text:
50 Years of Inquiries in the National Health Service. Polit Q. 2019;90:177-342.
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psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - CYP450 Drugs: Expect the Unexpected
Citation Text:
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/issue/independent-review-gross-negligence-manslaughter-and-culpable-homicide
July 08, 2019 - Book/Report
Independent Review of Gross Negligence Manslaughter and Culpable Homicide.
Citation Text:
Independent Review of Gross Negligence Manslaughter and Culpable Homicide. Manchester, UK: General Medical Council; June 2019.
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psnet.ahrq.gov/issue/human-error-cause-prediction-and-reduction
July 13, 2016 - Book/Report
Classic
Human Error: Cause, Prediction and Reduction.
Citation Text:
Human Error: Cause, Prediction and Reduction. Senders JW, Morey NP. Hillsdale NJ: L. Erlbaum Associates; 1991. ISBN: 9780898595987.
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psnet.ahrq.gov/issue/pediatric-safety
March 08, 2015 - Newspaper/Magazine Article
Pediatric safety.
Citation Text:
Runy LA. Pediatric safety. Hospitals & health networks. 2009;83(5):8 p following 32, 2.
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