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psnet.ahrq.gov/periodic-issue/periodic-issue-289
April 28, 2021 - The supplemental item set was released in time for the scheduled Fall 2021 MOSOPS data submission.
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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
March 15, 2021 - May 26, 2021
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/web-mm/see-patient-first
September 27, 2023 - 2) activation of a code or rapid response, 3) a significant change in clinical status, 4) a patient fall
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psnet.ahrq.gov/node/863649/psn-pdf
February 28, 2024 - In Conversation With...Stephen Hines, PhD and Monika
Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS
3.0
February 28, 2024
In Conversation With..Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about
TeamSTEPPS 3.0. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withstephen-…
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psnet.ahrq.gov/node/33750/psn-pdf
May 01, 2013 - measures, it's pretty hard to measure diagnostic
errors for example, and some of the other issues that fall
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psnet.ahrq.gov/node/857059/psn-pdf
November 29, 2023 - .7,8,10,11 In this case, the patient had none of these risk
factors, so there was no missed opportunity for prevention … Prevention and management of major complications in percutaneous
endoscopic gastrostomy.
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psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
November 27, 2023 - patient care learning activities in four spheres of care across the lifespan: wellness and disease prevention … September 30, 2020
Effect of an emergency department process improvement package on suicide prevention
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - or paravertebral steroid injections. 14 Blunt spinal trauma, such as a motor vehicle collision or fall
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psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
March 10, 2021 - engaged person in my care, I can work with my nurses so that they have good quality information about my fall … Related Resources
Patient Safety Innovations
Suicide Prevention
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psnet.ahrq.gov/perspective/conversation-james-augustine-md
July 28, 2021 - I serve as a subject matter expert with CDC [the Centers for Disease Control and Prevention] in emergency … diagnostic decision making, but also fundamental patient safety topics such as teamwork, infection prevention
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psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
January 01, 2021 - and then was lost to follow up.
5
Case Details (2)
• The patient re-presented to the ED after a fall
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psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
February 01, 2007 - The real world of medicine doesn't fall neatly into lists like that.
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Blunt spinal trauma, such as a motor vehicle collision or fall,
can lead to disruption of normal anatomic
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - Annual Perspective
Ensuring Patient and Workforce Safety Culture in Healthcare
John Murray, Joann Sorra, Bryan Gale, Sarah Mossburg
| March 27, 2024
View more articles from the same authors.
Citation Text:
Murray J, Sorra J, Gale B, et al. Ensuring Patient…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
June 01, 2010 - Does it help that you're aware of the possible holes that you may fall into, or are there more specific
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psnet.ahrq.gov/node/73902/psn-pdf
September 29, 2021 - vertebral or paravertebral steroid injections.14 Blunt spinal trauma,
such as a motor vehicle collision or fall
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psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement
March 10, 2021 - engaged person in my care, I can work with my nurses so that they have good quality information about my fall … July 10, 2024
Patient Safety Innovations
Suicide Prevention
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - diagnostic decision making, but also fundamental patient safety topics such as teamwork, infection prevention … I serve as a subject matter expert with CDC [the Centers for Disease Control and Prevention] in emergency
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - SPOTLIGHT CASE
Spotlight: Mistaken Attribution, Diagnostic Misstep
Citation Text:
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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