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psnet.ahrq.gov/node/41748/psn-pdf
April 05, 2013 - Factors contributing to all-cause 30-day readmissions: a
structured case series across 18 hospitals.
April 5, 2013
Feigenbaum P, Neuwirth E, Trowbridge L, et al. Factors contributing to all-cause 30-day readmissions: a
structured case series across 18 hospitals. Med Care. 2012;50(7):599-605.
doi:10.1097/MLR.0b013e…
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psnet.ahrq.gov/node/42395/psn-pdf
July 31, 2013 - Return on investment for vendor computerized physician
order entry in four community hospitals: the importance
of decision support.
July 31, 2013
Zimlichman E, Keohane C, Franz C, et al. Return on investment for vendor computerized physician order
entry in four community hospitals: the importance of decision suppo…
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psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
October 30, 2024 - facility efforts should focus on
Ensuring necessary staffing to schedule and complete home visits,
Establishing
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psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
September 23, 2024 - respiratory therapists, physical therapists, social workers, case management staff, and pharmacy staff)
Establishing
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psnet.ahrq.gov/node/33580/psn-pdf
April 01, 2022 - The process of establishing nurse staffing on a unit-by-unit and shift-by-shift basis is discussed in
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - Establishing a multisite education and research project requires leadership, expertise, collaboration
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - The process of establishing nurse staffing on a unit-by-unit and shift-by-shift basis is discussed in
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psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
February 01, 2012 - An Untimely End Despite End-of-Life Care Planning
Citation Text:
Elia G, Barbour S, Anderson WG. An Untimely End Despite End-of-Life Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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…
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psnet.ahrq.gov/node/39501/psn-pdf
January 03, 2017 - Harmful medication errors involving unfractionated and
low-molecular-weight heparin in three patient safety
reporting programs.
January 3, 2017
Grissinger MC, Hicks RW, Keroack MA, et al. Harmful medication errors involving unfractionated and low-
molecular-weight heparin in three patient safety reporting programs…
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psnet.ahrq.gov/node/39004/psn-pdf
April 04, 2011 - Balancing "no blame" with accountability in patient
safety.
April 4, 2011
Wachter R, Pronovost P. Balancing "no blame" with accountability in patient safety. New Engl J Med.
2009;361(14):1401-1406. doi:10.1056/NEJMsb0903885.
https://psnet.ahrq.gov/issue/balancing-no-blame-accountability-patient-safety
An early fo…
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psnet.ahrq.gov/node/39653/psn-pdf
November 15, 2011 - The new recommendations on duty hours from the
ACGME Task Force.
November 15, 2011
Nasca TJ, Day SH, Amis S, et al. The new recommendations on duty hours from the ACGME Task Force.
N Engl J Med. 2010;363(2):e3. doi:10.1056/NEJMsb1005800.
https://psnet.ahrq.gov/issue/new-recommendations-duty-hours-acgme-task-force
…
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psnet.ahrq.gov/primer/handoffs
October 18, 2023 - Handoffs
Citation Text:
Handoffs and Signouts. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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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/837958/psn-pdf
December 01, 2021 - EMS Perils from Hospital Overcrowding
August 31, 2022
Brown S, Rose JS, Barnes DK. EMS Perils from Hospital Overcrowding. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
The Case
A 71-year-old man with a history of postoperative septic knee arthritis (status: post-intravenous…
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psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - Becoming a Patient Safety Organization
Rory Jaffe, MD, MBA | July 1, 2011
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. Rockville (MD): Agency for Healthcare …
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psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
October 01, 2007 - Establishing a just culture within an organization requires action on three fronts: building awareness
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety
Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD
| August 30, 2023
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Van CM, Mossb…
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety
Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD
| August 30, 2023
Also Read the Essay
View more articles from the same authors. …
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psnet.ahrq.gov/issue/simulation-surgical-training-and-practice
February 15, 2012 - Special or Theme Issue
Simulation in Surgical Training and Practice.
Citation Text:
Simulation in Surgical Training and Practice. Brown KM, Paige JT, eds. Surg Clin North Am. 2015;95:695-918.
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psnet.ahrq.gov/issue/massachusetts-coalition-prevention-medical-errors
February 05, 2014 - Multi-use Website
Massachusetts Coalition for the Prevention of Medical Errors.
Citation Text:
Massachusetts Coalition for the Prevention of Medical Errors. Massachusetts Coalition for the Prevention of Medical Errors
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - Low on the Totem Pole
December 1, 2005
Wachter R. Low on the Totem Pole. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/low-totem-pole
Case Objectives
Understand the concept of authority gradient
List steps that can be taken to increase communication across an authority gradient
Consider the current cultu…