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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
January 01, 2019 - .
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Case: Diagnostic Misstep (5)
After an evaluation by the critical care provider, a CT scan of the … Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards
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psnet.ahrq.gov/issue/quality-improvement-study-medication-error-leading-thyrotoxicosis-and-death
September 13, 2017 - May 7, 2014
Using in situ simulation to identify and resolve latent environmental threats
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psnet.ahrq.gov/issue/promoting-patient-safety-one-companys-example
April 05, 2017 - January 13, 2021
Safety competency: exploring the impact of environmental and personal
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psnet.ahrq.gov/issue/evaluation-healthcare-safety-climate-measurement-tool
August 08, 2018 - August 8, 2018
Using in situ simulation to identify and resolve latent environmental
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psnet.ahrq.gov/issue/improving-risk-management-lame-excuses-principled-practice
April 05, 2006 - Understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental
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psnet.ahrq.gov/web-mm/do-me-favor
September 12, 2016 - Privacy Gone Awry
May 1, 2004
WebM&M Cases
Environmental
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - When assessing medication errors, reviewers must also be aware of and properly assess human and environmental … Human and environmental factors, such as communication issues, fatigue, distractions, workflow inefficiencies
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psnet.ahrq.gov/periodic-issue/periodic-issue-456
September 25, 2024 - In this study, researchers used human-centered design principles, information from environmental scans
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - 28914519
https://www.ismp.org/Tools/guidelines/Insulin-Guideline.pdf
https://psnet.ahrq.gov//#references
Environmental
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psnet.ahrq.gov/node/50949/psn-pdf
February 26, 2020 - causes of errors were hand-
off communication problems, staff inattention, knowledge deficit, and environmental
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psnet.ahrq.gov/periodic-issue/periodic-issue-422
January 04, 2024 - of anesthesiology at Yale School of Medicine and is the director of the Yale Program on Healthcare Environmental
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psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - Contributors to Insulin-Related Errors in the Emergency Department.( 5-7 )
Environmental contributors
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - common causes of errors were hand-off communication problems, staff inattention, knowledge deficit, and environmental
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psnet.ahrq.gov/node/49585/psn-pdf
May 01, 2009 - Environmental risk
factors for delirium in hospitalized older people.
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psnet.ahrq.gov/node/33792/psn-pdf
September 01, 2015 - chronic condition that needs to be managed, like glucose or blood pressure but also lifestyle issues,
environmental … unwillingness to accept that—"this is all iDoctor stuff"—and it is more of the same of
treating the scan
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - not all, of patients’ determinants of health, from the health services themselves to the social and environmental … comprehensiveness) and providing whole-person care Understanding how determinants of health such as social and environmental … Working with patients to help them overcome barriers to equitable care, such as access and social and environmental … Environmental Scan of Primary Care-Based Efforts to Reduce Readmissions.
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - After an evaluation by the critical care provider, a CT scan of the chest revealed bilateral pulmonary … Inpatient suicide on mental health units in Veterans Affairs
(VA) hospitals: avoiding environmental
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - Environmental risk factors for delirium in hospitalized older people.
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psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
February 26, 2025 - chronic condition that needs to be managed, like glucose or blood pressure but also lifestyle issues, environmental … unwillingness to accept that—"this is all iDoctor stuff"—and it is more of the same of treating the scan
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psnet.ahrq.gov/curated-library/value-and-patient-safety
October 30, 2019 - including screening high-risk individuals, universal decolonization in intensive care units, hand hygiene, environmental