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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Jaenic Lee, MD Josh Fernel…
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psnet.ahrq.gov/node/33718/psn-pdf
October 01, 2011 - In Conversation With… Paul G. Shekelle, MD, MPH, PhD
October 1, 2011
In Conversation With… Paul G. Shekelle, MD, MPH, PhD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd
Editor's note: Dr. Shekelle is director of the Southern California Evidence-Based Practice Cen…
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Medication Mix-Up: From Bad to Worse
Citation Text:
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49669/psn-pdf
November 01, 2012 - Transfusion Overload
November 1, 2012
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfusion-overload
Case Objectives
Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit
below 30% are not supported by the evidence.…
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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Mismanagement of Delirium
May 1, 2016
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/mismanagement-delirium
The Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although
fitted with a cast at a regional ho…
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psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Transfer Troubles
June 1, 2012
Hains IM. Transfer Troubles. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfer-troubles
Case Objectives
Recognize that transfer of patients between hospitals is common.
Understand the frequency of errors and adverse events in the transfer of patients between hospitals.
…
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered
Nurses and Paramedics To Provide Home Visits to
Recently Discharged Patients at Highest Risk for Hospital
Readmission
April 7, 2022
https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-
paramedics-provide-home
Sum…
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psnet.ahrq.gov/submit-innovations-landing
February 26, 2025 - Breadcrumb
Home
Improvement Resources
Innovations
Innovation Submissions
Individuals or organizations are encouraged to submit new or reimagined patient safety innovations that have been implemented, evaluated, sustained, and demonstrate significant improvement to patient safet…
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psnet.ahrq.gov/issue/high-reliability-health-care
May 06, 2015 - Measurement Tool/Indicator
High Reliability in Health Care.
Citation Text:
High Reliability in Health Care. Joint Commission Center for Transforming Healthcare.
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psnet.ahrq.gov/issue/toolkit-improve-safety-mechanically-ventilated-patients
October 01, 2024 - Toolkit
Toolkit To Improve Safety for Mechanically Ventilated Patients.
Citation Text:
Agency for Healthcare Research and Quality . Toolkit To Improve Safety for Mechanically Ventilated Patients. August 2017.
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psnet.ahrq.gov/issue/flying-blind
January 18, 2023 - Newspaper/Magazine Article
Flying blind.
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April 29, 2009
View more articles from the same authors.
This article explores how inf…
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psnet.ahrq.gov/node/836843/psn-pdf
April 07, 2022 - eSIMPLER: a dynamic, electronic health record-integrated
checklist for clinical decision support during PICU daily
rounds.
April 7, 2022
Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist
for clinical decision support during PICU daily rounds. Pediatr Crit Care…
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psnet.ahrq.gov/node/42667/psn-pdf
December 30, 2014 - Culture and behaviour in the English National Health
Service: overview of lessons from a large multimethod
study.
December 30, 2014
Dixon-Woods M, Baker R, Charles K, et al. Culture and behaviour in the English National Health Service:
overview of lessons from a large multimethod study. BMJ Qual Saf. 2014;23(2):10…
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psnet.ahrq.gov/issue/ahrq-2009-annual-conference
December 24, 2008 - Meeting/Conference Proceedings
AHRQ 2009 Annual Conference.
Citation Text:
AHRQ 2009 Annual Conference. Agency for Healthcare Research and Quality; AHRQ.
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psnet.ahrq.gov/issue/ahrq-2008-annual-conference
December 24, 2008 - Government Resource
AHRQ 2008 Annual Conference.
Citation Text:
AHRQ 2008 Annual Conference. Agency for Healthcare Research and Quality; AHRQ.
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Lin…
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psnet.ahrq.gov/node/38837/psn-pdf
June 28, 2011 - A comparison of hospital adverse events identified by
three widely used detection methods.
June 28, 2011
Naessens JM, Campbell CR, Huddleston JM, et al. A comparison of hospital adverse events identified by
three widely used detection methods. Int J Qual Health Care. 2009;21(4):301-7.
doi:10.1093/intqhc/mzp027.
h…
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psnet.ahrq.gov/node/38825/psn-pdf
October 12, 2009 - Implementation of a mandatory checklist of protocols and
objectives improves compliance with a wide range of
evidence-based intensive care unit practices.
October 12, 2009
Byrnes MC, Schuerer DJE, Schallom ME, et al. Implementation of a mandatory checklist of protocols and
objectives improves compliance with a wid…
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psnet.ahrq.gov/issue/missed-signals
September 21, 2016 - Newspaper/Magazine Article
Missed signals.
Citation Text:
Missed signals. Sanders L. New York Times Magazine. April 22, 2007.
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psnet.ahrq.gov/issue/leapfrog-hospital-safety-scores-depressing
November 13, 2013 - Newspaper/Magazine Article
Leapfrog hospital safety scores 'depressing.'
Citation Text:
Leapfrog hospital safety scores 'depressing.' Clark C. HealthLeaders Media. May 9, 2013.
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psnet.ahrq.gov/issue/tips-topics-patient-safety
May 24, 2017 - Government Resource
TIPS (Topics in Patient Safety).
Citation Text:
TIPS (Topics in Patient Safety). National Center for Patient Safety.
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