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psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
May 01, 2009 - What have you learned and how would you change the educational process so that people have the skills
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psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
May 01, 2018 - Develop a consensus-based approach to addressing the error (could be technical, educational, or process-oriented
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psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
January 01, 2021 - Patricia Poole, PharmD
o Managing Editor: Meghan Weyrich, MPH
2
Objectives
At the conclusion of this educational
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psnet.ahrq.gov/perspective/what-makes-good-checklist
October 01, 2010 - October 24, 2018
Increasing reporting of adverse events to improve the educational value
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psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
May 01, 2008 - Develop a consensus-based approach to addressing the error (could be technical, educational, or process-oriented
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psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
September 27, 2023 - requires practice; it has been proposed that clinical handover skills should be taught formally in educational
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Editor: Meghan Weyrich, MPH
2
https://psnet.ahrq.gov/webmm
Objectives
At the conclusion of this educational
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psnet.ahrq.gov/node/33795/psn-pdf
November 01, 2015 - Introducing the Redesigned AHRQ Patient Safety Network
November 1, 2015
Wachter R. Introducing the Redesigned AHRQ Patient Safety Network . PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network
Editorial
It's hard to believe that it has been 15 years since th…
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic
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April 27, 2022
Innovation
Conta…
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psnet.ahrq.gov/node/49567/psn-pdf
September 01, 2008 - Empiric Steroids: the Good, the Bad, and the Ugly
September 1, 2008
Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
Case Objectives
Describe appropriate indications for use of steroids.
Appreciate contraindicati…
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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/node/49606/psn-pdf
August 01, 2010 - Weighing In on Surgical Safety
August 1, 2010
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/weighing-surgical-safety
Case Objectives
Identify the comorbidites associated with obesity that place patients at higher risk for surgical
complications.
Un…
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psnet.ahrq.gov/web-mm/reaction-dye
March 01, 2007 - Reaction to Dye
Citation Text:
Cohan R. Reaction to Dye. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/60745/psn-pdf
October 01, 2020 - Multiple High-Risk Events Involving Workflow for Wasting
of Medications Used by Anesthesia
July 29, 2020
Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications
Used by Anesthesia. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-high-risk-events-involvi…
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psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical
Record Causing an Accidental Medication Overdose
October 31, 2023
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an
Accidental Medication Overdose. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/weight-and-…
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psnet.ahrq.gov/node/33754/psn-pdf
September 01, 2013 - In Conversation With… Sidney Dekker, MA, MSc, PhD
September 1, 2013
In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
Editor's note: Sidney Dekker is Professor and Director of the Safety Science Innovation Lab at Grif…
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psnet.ahrq.gov/node/49864/psn-pdf
June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You
in Training About Feedback and Burnout
June 1, 2019
Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About
Feedback and Burnout. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - The Forgotten Line
Citation Text:
Render ML. The Forgotten Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - Coming Undone: Failure of Closure Device
Citation Text:
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar Bi…
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…