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psnet.ahrq.gov/node/39640/psn-pdf
June 30, 2010 - Beyond patient safety Flatland.
June 30, 2010
Braithwaite J, Coiera E. Beyond patient safety Flatland. J R Soc Med. 2010;103(6):219-25.
doi:10.1258/jrsm.2010.100032.
https://psnet.ahrq.gov/issue/beyond-patient-safety-flatland
This essay examines three dimensions of patient safety and emphasizes the need for a deep…
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psnet.ahrq.gov/node/37949/psn-pdf
May 24, 2015 - 2008 Recommendations for Pre-Anesthesia Checkout
Procedures.
May 24, 2015
ASA Committee on Equipment and Facilities. Park Ridge, IL: American Society of Anesthesiologists; 2008.
https://psnet.ahrq.gov/issue/2008-recommendations-pre-anesthesia-checkout-procedures
These guidelines explain how to examine equipment …
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psnet.ahrq.gov/node/40915/psn-pdf
January 04, 2012 - Simulation in obstetric anesthesia.
January 4, 2012
Pratt SD. Focused review: simulation in obstetric anesthesia. Anesth Analg. 2012;114(1):186-90.
doi:10.1213/ANE.0b013e3182377bbc.
https://psnet.ahrq.gov/issue/simulation-obstetric-anesthesia
This review examines how simulation training can improve performance, id…
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psnet.ahrq.gov/node/42217/psn-pdf
December 18, 2013 - A concept analysis of situational awareness in nursing.
December 18, 2013
Fore AM, Sculli GL. A concept analysis of situational awareness in nursing. J Adv Nurs. 2013;69(12):2613-
21. doi:10.1111/jan.12130.
https://psnet.ahrq.gov/issue/concept-analysis-situational-awareness-nursing
This review examines situational…
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psnet.ahrq.gov/node/42325/psn-pdf
March 02, 2023 - Hospital discharge and readmission.
March 2, 2023
Alper E, O'Malley TA, Greenwald J. UpToDate. February 3, 2023.
https://psnet.ahrq.gov/issue/hospital-discharge-and-readmission
This review examines hospital discharge, details elements of the process that can increase risk of
readmission, and reveals interventions …
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www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-summary/chronic-obstructive-pulmonary-disease-screening-2016
April 05, 2016 - There was little evidence examining the potential negative effect of COPD screening on targeted preventive … in patients naive to maintenance treatment with moderate COPD (n = 457) 55 and 4 subgroup analyses examining … Evidence examining dyspnea scores and exercise capacity scant. … Key question 8: Treatment harms
Asymptomatic screen-detected patients
No trials examining
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/measuring-blood-pressure_disposition-comments.pdf
January 01, 2012 - recommended future research on the accuracy
of SMBP: “Other important areas for future research
include examining … “Our findings are consistent with four recently
published systematic reviews examining the effect of
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psnet.ahrq.gov/node/37293/psn-pdf
June 16, 2019 - ISMP medication error report analysis.
June 16, 2019
Cohen MR; Smetzer JL. Hosp Pharm. 2007;42(10):884-887.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-18
This monthly analysis examines recently reported errors in prescribing fentanyl patches, ordering insulin,
and administering vincristine.…
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www.ahrq.gov/research/shuttered/toolkitchecklist/facancil.html
July 01, 2018 - Facilities/Ancillary Services
Availability of other space for ancillary services. Examine general condition of facilities. Other experts will look at these areas from a different perspective.
Date: ____________ Location: _______________________ Team member: __________________________
Administrative Areas …
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide191.html
October 01, 2014 - 191. Specific Populations and Other Topics (Continued)
Treating Tobacco Use and Dependence: 2008 Update
Text version of slide presentation.
Evidence of effectiveness of tobacco dependence interventions in specific populations
Population of Smokers
Review of Evidence
HIV-positive
No long-…
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psnet.ahrq.gov/node/35528/psn-pdf
February 22, 2010 - The Swiss cheese model of safety incidents: are there
holes in the metaphor?
February 22, 2010
Perneger T. The Swiss cheese model of safety incidents: are there holes in the metaphor? BMC Health
Serv Res. 2005;5:71.
https://psnet.ahrq.gov/issue/swiss-cheese-model-safety-incidents-are-there-holes-metaphor
The auth…
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psnet.ahrq.gov/node/39410/psn-pdf
March 31, 2010 - Doctors fear work caps for residents may be bad
medicine.
March 31, 2010
Shapira I.
https://psnet.ahrq.gov/issue/doctors-fear-work-caps-residents-may-be-bad-medicine
This news piece examines the work week of resident physicians and discusses how further limiting
trainees' work hours might reduce their experientia…
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psnet.ahrq.gov/node/40847/psn-pdf
October 12, 2011 - Human and organizational biases affecting the
management of safety.
October 12, 2011
Reiman T, Rollenhagen C. Human and organizational biases affecting the management of safety. Reliab
Eng Syst Saf. 2011;96(10). doi:10.1016/j.ress.2011.05.010.
https://psnet.ahrq.gov/issue/human-and-organizational-biases-affecting-…
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psnet.ahrq.gov/node/41350/psn-pdf
May 02, 2012 - Medication reconciliation in the hospital: what, why,
where, when, who and how?
May 2, 2012
Fernandes O; Shojania KG.
https://psnet.ahrq.gov/issue/medication-reconciliation-hospital-what-why-where-when-who-and-how
This commentary examines the practical considerations required to implement a high quality medication…
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psnet.ahrq.gov/node/37834/psn-pdf
September 08, 2010 - Patient Safety in Public Hospitals.
September 8, 2010
Victorian Auditor-General's Office. Melbourne, Australia: Victorian Government Printer; 2008. ISBN:
1921060689.
https://psnet.ahrq.gov/issue/patient-safety-public-hospitals
This report examined patient safety in public hospitals in the state of Victoria (Austra…
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psnet.ahrq.gov/node/39224/psn-pdf
August 11, 2015 - Diagnostic error and clinical reasoning.
August 11, 2015
Norman GR, Eva KW. Diagnostic error and clinical reasoning. Med Educ. 2010;44(1):94-100.
doi:10.1111/j.1365-2923.2009.03507.x.
https://psnet.ahrq.gov/issue/diagnostic-error-and-clinical-reasoning
This article reviews evidence on the cognitive origins of diag…
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psnet.ahrq.gov/node/41842/psn-pdf
March 08, 2015 - Patient safety in the OR.
March 8, 2015
Stempniak M. Patient safety in the OR. Hospitals & health networks. 2012;86(10):8 p following 40.
https://psnet.ahrq.gov/issue/patient-safety-or-0
This article examines patient safety concerns in the operating room, including their causes and how
teamwork, checklists, and im…
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psnet.ahrq.gov/node/34014/psn-pdf
January 25, 2008 - Medication errors in pediatrics—the octopus evading
defeat.
January 25, 2008
Sullivan JE, Buchino JJ. Medication errors in pediatrics--the octopus evading defeat. J Surg Oncol.
2004;88(3):182-8.
https://psnet.ahrq.gov/issue/medication-errors-pediatrics-octopus-evading-defeat
This review examines pediatric medicat…
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psnet.ahrq.gov/node/39312/psn-pdf
February 17, 2010 - Patient safety in dermatology: a review of the literature.
February 17, 2010
Cao LY, Taylor JS, Vidimos A. Patient safety in dermatology: a review of the literature. Dermatol Online J.
2010;16(1):3.
https://psnet.ahrq.gov/issue/patient-safety-dermatology-review-literature
This review examines numerous safety issue…
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psnet.ahrq.gov/node/38881/psn-pdf
November 08, 2012 - Are patients in part to blame when doctors miss the
diagnosis?
November 8, 2012
Chen PW
https://psnet.ahrq.gov/issue/are-patients-part-blame-when-doctors-miss-diagnosis
This column recounts a case of delayed diagnosis and examines how communication and process of care
failures can contribute to diagnostic errors.…