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psnet.ahrq.gov/issue/reducing-risk-maternity-optimising-teamwork-and-leadership-evidence-based-approach-save
January 06, 2016 - Review
Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies.
Citation Text:
Cornthwaite K, Edwards S, Siassakos D. Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mot…
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psnet.ahrq.gov/issue/peer-review-medical-practices-missed-opportunities-learn
November 16, 2022 - Commentary
Peer review of medical practices: missed opportunities to learn.
Citation Text:
Kadar N. Peer review of medical practices: missed opportunities to learn. Am J Obstet Gynecol. 2014;211(6):596-601. doi:10.1016/j.ajog.2014.08.018.
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psnet.ahrq.gov/issue/interruptions-during-nurses-work-state-science-review
October 21, 2009 - Review
Interruptions during nurses' work: a state-of-the-science review.
Citation Text:
Hopkinson SG, Jennings BM. Interruptions during nurses' work: A state-of-the-science review. Res Nurs Health. 2013;36(1):38-53. doi:10.1002/nur.21515.
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psnet.ahrq.gov/issue/role-cognitive-bias-breast-radiology-diagnostic-and-judgment-errors
April 24, 2018 - Commentary
The role of cognitive bias in breast radiology diagnostic and judgment errors.
Citation Text:
Loving VA, Valencia EM, Patel B, et al. The role of cognitive bias in breast radiology diagnostic and judgment errors. J Breast Imag. 2020. doi:10.1093/jbi/wbaa023.
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psnet.ahrq.gov/issue/literature-review-do-rapid-response-systems-reduce-incidence-major-adverse-events
April 22, 2015 - Review
Literature review: do rapid response systems reduce the incidence of major adverse events in the deteriorating ward patient?
Citation Text:
Massey D, Aitken LM, Chaboyer W. Literature review: do rapid response systems reduce the incidence of major adverse events in the deteriora…
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - SPOTLIGHT CASE
Diagnosing HIV-It Doesn't Take a Brain Surgeon
Citation Text:
Chou R. Diagnosing HIV-It Doesn't Take a Brain Surgeon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/47134/psn-pdf
March 04, 2019 - Association of hydrocodone schedule change with opioid
prescriptions following surgery.
March 4, 2019
Habbouche J, Lee JS, Steiger R, et al. Association of Hydrocodone Schedule Change With Opioid
Prescriptions Following Surgery. JAMA Surg. 2018;153(12):1111-1119. doi:10.1001/jamasurg.2018.2651.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/43049/psn-pdf
October 31, 2014 - Vital signs: improving antibiotic use among hospitalized
patients.
October 31, 2014
Fridkin SK, Baggs J, Fagan R, et al. Vital signs: improving antibiotic use among hospitalized patients.
MMWR Morb Mortal Wkly Rep. 2014;63(9):194-200.
https://psnet.ahrq.gov/issue/vital-signs-improving-antibiotic-use-among-hospital…
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psnet.ahrq.gov/node/45407/psn-pdf
September 27, 2016 - Safety of the Manchester Triage System to detect
critically ill children at the emergency department.
September 27, 2016
Zachariasse JM, Kuiper JW, de Hoog M, et al. Safety of the Manchester Triage System to Detect Critically
Ill Children at the Emergency Department. J Pediatr. 2016;177:232-237.e1.
doi:10.1016/j.j…
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psnet.ahrq.gov/node/37166/psn-pdf
February 03, 2011 - Mortality among hospitalized Medicare beneficiaries in
the first 2 years following ACGME resident duty hour
reform.
February 3, 2011
Meltzer DO, Arora VM. Evaluating Resident Duty Hour Reforms. JAMA. 2007;298(9).
doi:10.1001/jama.298.9.1055.
https://psnet.ahrq.gov/issue/mortality-among-hospitalized-medicare-benef…
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psnet.ahrq.gov/node/33691/psn-pdf
December 01, 2009 - How to Identify and Manage Problem Behaviors
December 1, 2009
Rosenstein AH, O'Daniel M. How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
Perspective
The 1999 Institute of Medicine report highlighted the need for heal…
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psnet.ahrq.gov/node/33709/psn-pdf
July 01, 2011 - What Have We Learned About Safe Inpatient Handovers?
March 1, 2011
Kripalani S. What Have We Learned About Safe Inpatient Handovers? PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
Perspective
The care of hospitalized patients is marked by numerous tra…
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psnet.ahrq.gov/node/49809/psn-pdf
October 01, 2017 - Hyperbilirubinemia Refractory to Phototherapy
October 1, 2017
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
The Case
A 1-day-old full-term infant was noted to have elevated total serum bilirubin (…
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psnet.ahrq.gov/web-mm/deciphering-code
November 16, 2022 - Deciphering the Code
Citation Text:
Goldstein MK. Deciphering the Code. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - the
quantitative end-tidal carbon dioxide (CO2) value is displayed—allows clinicians to quickly and effectively
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psnet.ahrq.gov/primer/teamwork-training
September 15, 2024 - Teamwork Training
Citation Text:
Teamwork Training. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Dow…
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx
Spotlight
A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion
Source and Credits
• This presentation is based on the July 2023 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/issue/if-only-failed-missed-and-absent-error-recovery-opportunities-medication-errors
July 15, 2009 - Study
If only...: failed, missed and absent error recovery opportunities in medication errors.
Citation Text:
Habraken MMP, van der Schaaf TW. If only..: failed, missed and absent error recovery opportunities in medication errors. Qual Saf Health Care. 2010;19(1):37-41. doi:10.1136/qsh…
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psnet.ahrq.gov/issue/improving-patient-safety-effects-safety-program-performance-and-culture-department-radiology
May 12, 2010 - Study
Improving patient safety: effects of a safety program on performance and culture in a department of radiology.
Citation Text:
Donnelly LF, Dickerson JM, Goodfriend MA, et al. Improving patient safety: effects of a safety program on performance and culture in a department of radiolo…
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psnet.ahrq.gov/issue/barriers-staff-adoption-surgical-safety-checklist
February 25, 2015 - Study
Barriers to staff adoption of a surgical safety checklist.
Citation Text:
Fourcade A, Blache J-L, Grenier C, et al. Barriers to staff adoption of a surgical safety checklist. BMJ Qual Saf. 2012;21(3):191-7. doi:10.1136/bmjqs-2011-000094.
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