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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - SPOTLIGHT CASE
Difficult Encounters: A CMO and CNO Respond
Citation Text:
Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/49564/psn-pdf
July 01, 2008 - Dependence vs. Pain
July 1, 2008
Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/dependence-vs-pain
Case Objectives
Define opioid dependence and opioid withdrawal syndrome.
Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid
Withdra…
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - Complications of ECMO During Transport
April 29, 2020
Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
The Case
A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with
acute on chro…
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - Annual Perspective
Annual Perspective: Topics in Medication Safety
March 31, 2022
View more articles from the same authors.
Citation Text:
Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - SPOTLIGHT CASE
Getting to the Root of the Matter
Citation Text:
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Google Schola…
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Intraoperative Awareness during Rhinoplasty
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: Christian Bohringer MBBS and Jaijeet Toor MD
AHRQ WebM&M Edit…
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psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
June 09, 2021 - Book/Report
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.
Citation Text:
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
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psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they-do-and-how-fix-it
November 20, 2019 - Newspaper/Magazine Article
Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it.
Citation Text:
Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Park A. Time Magazine. January 24, 2019.
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psnet.ahrq.gov/issue/american-college-radiology-white-paper-mr-safety-2004-update-and-revisions
September 28, 2022 - Clinical Guideline
American College of Radiology White Paper on MR Safety: 2004 Update and Revisions.
Citation Text:
doi:10.2214/ajr.182.5.182111.
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DOI BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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…
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psnet.ahrq.gov/issue/seeing-systems-health-care-organizations
January 25, 2023 - Commentary
Seeing systems in health care organizations.
Citation Text:
Friedman LH, King JB, Bella D. Seeing systems in health care organizations. Physician Exec. 2007;33(4):20-9.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
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psnet.ahrq.gov/issue/strategies-improve-patient-safety-final-report-congress-required-patient-safety-and-quality
June 21, 2016 - Book/Report
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.
Citation Text:
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.…
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psnet.ahrq.gov/issue/communication-and-teamwork-patient-care-how-much-can-we-learn-aviation
August 12, 2019 - Review
Communication and teamwork in patient care: how much can we learn from aviation?
Citation Text:
Lyndon A. Communication and teamwork in patient care: how much can we learn from aviation? J Obstet Gynecol Neonatal Nurs. 2006;35(4):538-46.
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Googl…
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psnet.ahrq.gov/issue/concept-analysis-systems-thinking
August 20, 2018 - Review
A concept analysis of systems thinking.
Citation Text:
Stalter AM, Phillips JM, Ruggiero JS, et al. A Concept Analysis of Systems Thinking. Nurs Forum. 2017;52(4):323-330. doi:10.1111/nuf.12196.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/issue/thinking-fast-and-slow-medicine
June 21, 2017 - Commentary
Thinking fast and slow in medicine.
Citation Text:
Michel JB. Thinking fast and slow in medicine. Baylor U Med Center Proceed. 2019;33(1):123-125. doi:10.1080/08998280.2019.1674043.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/issue/improving-patient-understanding-prescription-drug-label-instructions
April 16, 2010 - Study
Improving patient understanding of prescription drug label instructions.
Citation Text:
Davis TC, Federman AD, Bass PF, et al. Improving patient understanding of prescription drug label instructions. J Gen Intern Med. 2009;24(1):57-62. doi:10.1007/s11606-008-0833-4.
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psnet.ahrq.gov/issue/documenting-day-discussion-ahead-crest-wave-creating-national-agenda-systemic-change-enhanced
April 28, 2021 - Book/Report
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change for Enhanced Clinician Well-Being.
Citation Text:
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change …
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psnet.ahrq.gov/issue/junior-doctors-shifts-and-sleep-deprivation
October 16, 2012 - Commentary
Junior doctors' shifts and sleep deprivation.
Citation Text:
Murray A, Pounder R, Mather H, et al. Junior doctors' shifts and sleep deprivation. BMJ. 2005;330(7505):1404.
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psnet.ahrq.gov/issue/role-automation-complex-system-failures
June 28, 2013 - Commentary
The role of automation in complex system failures.
Citation Text:
Perry SJ, Wears RL, Cook RI. The role of automation in complex system failures. J Patient Saf. 2005;1(1):56-61. https://journals.lww.com/journalpatientsafety/Fulltext/2005/03000/The_Role_of_Automation_in_Compl…