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psnet.ahrq.gov/perspective/context-intervention
August 05, 2020 - The Context Is the Intervention
Dr. John Øvretveit | October 1, 2011
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Citation Text:
Øvretveit J. The Context Is the Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple
Health System Vulnerabilities
May 26, 2021
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health
System Vulnerabilities. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…
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psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - The Physical Environment: An Often Unconsidered Patient Safety Tool
Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC | October 1, 2012
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Citation Text:
Joseph A, Malone EB. The Physical Environment: An Often Unc…
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - Abnormal Volunteer Results
Citation Text:
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care
Rapid Response for Perinatal Safety
Rapid Response for Perinatal Safety
SAY:
The Rapid Response for Perinatal Safety bundle provides information establishing a unitwide approach, also referred to as a rapid response system, for responding to urgent maternity care issues.
Slide …
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psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - Good Catch in the Operating Room
May 1, 2019
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/good-catch-operating-room
The Case
A 46-year-old woman with extensive history of back pain from lumbar stenosis was scheduled for an
elective laminectomy and spinal…
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psnet.ahrq.gov/web-mm/raise-bar
May 29, 2024 - Raise the Bar
Citation Text:
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/836939/psn-pdf
April 27, 2022 - A Virtual Hospitalist Program to Address a Hospital’s
Challenges at the Start of the COVID-19 Pandemic
April 27, 2022
https://psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-
pandemic
Summary
In the early days of the COVID-19 pandemic, New York Presbyterian Weill …
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cdsic.ahrq.gov/sites/default/files/2022-04/Final%20Innovation%20Center%20Charter_508.pdf
January 01, 2022 - Final Innovation Center Charter
FINAL INNOVATION CENTER CHARTER
A p r i l 6 , 2 0 2 2
Agency for Healthcare
Research and Quality:
Clinical Decision Support
Innovation Collaborative
(CDSiC)
Presented by:
NORC at the University of Chicago
4350 East-West Highway Suite 800
Bethesda, MD 20814
…
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psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
June 28, 2023 - Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling
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January 31, 2024
Innovation
Contact
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psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
June 16, 2021 - Adverse Event During Intrahospital Transport
Citation Text:
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. 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/node/850678/psn-pdf
June 14, 2023 - Advance Alert Monitor Program: An Automated Early
Warning System for Adults At Risk for In-Hospital Clinical
Deterioration
June 14, 2023
https://psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-
risk-hospital
Summary
To address a well-documented hospital adverse outco…
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psnet.ahrq.gov/node/849592/psn-pdf
May 31, 2023 - Preventing Falls Through Patient and Family Engagement
to Create Customized Prevention Plans
May 31, 2023
https://psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-
customized-prevention
Summary
Patient falls in hospitals are common and debilitating adverse events that persis…
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - Baffled by Botulinum Toxin
Citation Text:
Sivaraman-Nair KP. Baffled by Botulinum Toxin. 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/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
July 01, 2004 - Hip Fractures in Older Patients: the Case for Geriatrics Comanagement
Citation Text:
Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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www.ahrq.gov/sites/default/files/2024-07/aboumatar-report.pdf
January 01, 2024 - i.e., meeting ‘top ranking’ or ‘most
improved’ criteria), a letter was sent to the hospital’s Chief Executive
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - – or RCA Squared (RCA 2 ) –an online self-paced course IHI offers, as well as the Patient Safety Executive
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - – or RCA Squared (RCA 2 ) –an online self-paced course IHI offers, as well as the Patient Safety Executive
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psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
May 14, 2020 - You need to get buy-in from the larger organization, the executive leadership.
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/MLeu_yFpPwzcZwKG6fw5ZY
April 26, 2022 - Gaziano JM, Brotons C, Coppolecchia R, et al;
ARRIVE Executive Committee. … Executive Summary of the Third Report of the
National Cholesterol Education Program (NCEP)
Expert Panel