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psnet.ahrq.gov/node/42510/psn-pdf
August 21, 2013 - Root cause analysis reports help identify common factors
in delayed diagnosis and treatment of outpatients.
August 21, 2013
Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in
delayed diagnosis and treatment of outpatients. Health Aff (Millwood). 2013;32(8):1368-75.…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
November 01, 2011 - Spotlight Case July 2008
Spotlight Case
Near Miss with Bedside Medications
*
*
Source and Credits
This presentation is based on the November 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Albert W. Wu, MD, MPH, Johns Hopkins Bloomberg S…
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psnet.ahrq.gov/primer/rapid-response-systems
July 18, 2024 - Rapid Response Systems
Citation Text:
Rapid Response Systems. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior
September 15, 2024 - Disruptive and Unprofessional Behavior
Citation Text:
Disruptive and Unprofessional Behavior. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy
March 10, 2021
Also Read the Essay
Citation Text:
In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021.In Conversation With... Libby Hoy and Stephen Hoy. PSNet [internet]. Rockville (MD): Agenc…
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psnet.ahrq.gov/node/42099/psn-pdf
March 13, 2013 - Inpatient fall prevention programs as a patient safety
strategy: a systematic review.
March 13, 2013
Miake-Lye IM, Hempel S, Ganz DA, et al. Inpatient fall prevention programs as a patient safety strategy: a
systematic review. Ann Intern Med. 2013;158(5 Pt 2):390-396. doi:10.7326/0003-4819-158-5-201303051-
00005.
…
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psnet.ahrq.gov/node/39116/psn-pdf
April 30, 2014 - Diagnostic error in medicine: analysis of 583 physician-
reported errors.
April 30, 2014
Schiff G, Hasan O, Kim S, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors.
Arch Intern Med. 2009;169(20):1881-1887. doi:10.1001/archinternmed.2009.333.
https://psnet.ahrq.gov/issue/diagnostic-err…
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psnet.ahrq.gov/issue/spread-remains-challenge-patient-safety-improvement
January 23, 2019 - Newspaper/Magazine Article
'Spread' remains challenge in patient safety improvement.
Citation Text:
'Spread' remains challenge in patient safety improvement. Healthcare benchmarks and quality improvement. 2011;18(5):49-52.
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psnet.ahrq.gov/node/44026/psn-pdf
November 03, 2015 - Effect of a postdischarge virtual ward on readmission or
death for high-risk patients: a randomized clinical trial.
November 3, 2015
Dhalla IA, O'Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high-
risk patients: a randomized clinical trial. JAMA. 2014;312(13):1305-12. …
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psnet.ahrq.gov/node/840172/psn-pdf
November 16, 2022 - The Stoplight Mobility Alert System for safety and
prevention of falls in children with physical and cognitive
impairments.
November 16, 2022
Mullen JB, Wirt SZ, Moser A, et al. J Patient Saf. 2022;18(6):e947-e952
https://psnet.ahrq.gov/innovation/stoplight-mobility-alert-system-safety-and-prevention-fal…
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psnet.ahrq.gov/issue/why-physicians-err-diagnosis
March 27, 2024 - Commentary
Why physicians err in diagnosis.
Citation Text:
Why physicians err in diagnosis. JAMA. 2015;313(12):1273. doi:10.1001/jama.2014.11660.
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psnet.ahrq.gov/node/845356/psn-pdf
March 29, 2023 - A novel approach for engagement in team training in
high-technology surgery: the robotic-assisted surgery
olympics.
March 29, 2023
Cohen TN, Anger JT, Kanji FF, et al. A novel approach for engagement in team training in high-technology
surgery: the robotic-assisted surgery olympics. J Patient Saf. 2022;18(6):570-5…
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psnet.ahrq.gov/issue/creating-culture-safety-opioid-prescribing-handbook-healthcare-executives
May 01, 2023 - Toolkit
Creating a Culture of Safety for Opioid Prescribing: A Handbook for Healthcare Executives.
Citation Text:
Centers for Disease Control and Prevention (CDC); 2021. Creating a Culture of Safety for Opioid Prescribing: A Handbook for Healthcare Executives.
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psnet.ahrq.gov/issue/opioid-taskforce-playbook
May 01, 2023 - Toolkit
Opioid Taskforce Playbook.
Citation Text:
College of Healthcare Information Management Executives; 2023. Opioid Taskforce Playbook.
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…
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
March 24, 2025 - Someone who is not evaluating them, but who can provide an objective sophisticated assist to help them
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psnet.ahrq.gov/node/49717/psn-pdf
September 01, 2014 - All of these factors can result in under-treatment of pain in this patient population.(
5)
When evaluating
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psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - before any adverse effect occurred.(19) When not
automated, a second pharmacist should be involved in evaluating
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - ) Third, it underscores the potential for medical errors in end-of-life care and the difficulty in evaluating
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psnet.ahrq.gov/node/866343/psn-pdf
December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure
with Hypertensive Emergency
December 31, 2024
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive
Emergency. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hyperte…
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psnet.ahrq.gov/web-mm/snfs-opening-black-box
August 27, 2012 - SNFs: Opening the Black Box
Citation Text:
Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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