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psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - Organizations often develop error prevention strategies following a serious event that focus solely on … The error occurs when individuals fall victim to the flaws within the system and mistakes are made.
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - stenosis)
• Patient was admitted for a pathologic pelvic fracture
(secondary to osteoporosis) after a fall … Pressure Ulcer Prevention in the Hospital Setting Using Silicone Foam Dressings.
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psnet.ahrq.gov/perspective/patient-engagement-safety
January 01, 2018 - March 13, 2024
Patient and caregiver perspectives on causes and prevention of ambulatory
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psnet.ahrq.gov/periodic-issue/periodic-issue-439
May 29, 2024 - improvement following the nurse manager visit was improved access into the home and a reduction in trip and fall … A culture that fosters awareness and prevention of fatigue can improve not only patient safety, but also
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psnet.ahrq.gov/innovation/duke-pediatric-residency-safety-council
November 16, 2022 - Journal Article
Study
Catching those who fall … Article
Study
The Stoplight Mobility Alert System for safety and prevention
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psnet.ahrq.gov/web-mm/think-surgeon
December 04, 2024 - October 19, 2022
ROI for a fall prevention intervention: invest a little, save a lot.
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - providers who all noted that the hemoglobin remained stable at 12 g/dL, and the bilirubin continued to fall
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psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
June 01, 2011 - Or are there ways to prospectively anticipate that something is likely to fall off the back of the truck … The back of a patient chair on a tomography system bent and broke off, allowing a patient to fall.
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psnet.ahrq.gov/issue/computer-based-provider-order-entry-cpoe
July 20, 2022 - January 26, 2022
Evaluation of clinical practice guidelines on fall prevention and management
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psnet.ahrq.gov/periodic-issue/periodic-issue-348
May 16, 2022 - June 29, 2022 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/Webmm
May 01, 2021 - Level III trauma center to a Level I trauma center with lower extremity paralysis after a ground level fall
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psnet.ahrq.gov/webmm
May 01, 2021 - Level III trauma center to a Level I trauma center with lower extremity paralysis after a ground level fall
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - reporting hospital-specific mortality following coronary bypass surgery, mortality rates were observed to fall … Smoking cessation advice/counseling Appropriate Initial Antibiotic Selection Surgical Infection Prevention
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - April 1, 2014
Perspective
How Does Infection Prevention
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psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
December 01, 2017 - Effect of computerized physician order entry and a team intervention on prevention of serious medication
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psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - Innovations
Preventing Falls Through Patient and Family Engagement to Create Customized Prevention
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psnet.ahrq.gov/web-mm/poor-prognosis
March 15, 2016 - Innovations
Preventing Falls Through Patient and Family Engagement to Create Customized Prevention
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psnet.ahrq.gov/node/49630/psn-pdf
July 01, 2011 - Cost-effectiveness of dabigatran compared with warfarin for
stroke prevention in atrial fibrillation
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psnet.ahrq.gov/node/49429/psn-pdf
January 01, 2004 - Unfortunately, ß-hCG levels alone are not diagnostic as they may fall and rise in
some situations, such
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psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
November 01, 2016 - of Electronic Order Sets
November 1, 2016
Centers for Disease Control and Prevention … Guideline for the Prevention of Surgical Site Infection, 2017. … Innovations
Preventing Falls Through Patient and Family Engagement to Create Customized Prevention