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psnet.ahrq.gov/web-mm/missing-suction-tip
January 01, 2006 - SPOTLIGHT CASE
The Missing Suction Tip
Citation Text:
Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/infused-not-ingested
February 01, 2017 - Infused, Not Ingested
Citation Text:
Foley M. Infused, Not Ingested. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/clinical-areas
March 24, 2025 - Clinical Areas
Scroll down to search or browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nurse care or medical specialty, featured in the resources.
Latest by Clinical Areas
In Conversation with Edwin Boudreaux about S…
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psnet.ahrq.gov/node/49544/psn-pdf
September 01, 2007 - Discharging Our Responsibility
September 1, 2007
Fonarow GC. Discharging Our Responsibility. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/discharging-our-responsibility
The Case
A 75-year-old man with a history of hypertension, coronary artery disease, and congestive heart failure
(CHF) presented to the …
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psnet.ahrq.gov/print/pdf/node/865308
January 01, 2024 - This commentary presents a model to help organizations learn from system
failures through focusing on … This commentary presents a model to help organizations learn from system
failures through focusing on
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psnet.ahrq.gov/node/852698/psn-pdf
August 30, 2023 - Many methods of reducing diagnostic error focus on individual factors and single
cases, instead of focusing … eB seeks to improve the systems that
cause diagnostic errors and patient safety events rather than focusing
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psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
September 24, 2024 - harm is thought to arise from linear, repeated processes that can be reliably improved, can result in focusing … Instead, with “Safety II,” risk reduction can motivate improvements in patient safety by focusing on … They become good by focusing on improvement and getting better. … is these small things that you focus on daily that create excellence and improvement over time, not focusing
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psnet.ahrq.gov/node/33616/psn-pdf
August 01, 2005 - A strong evidence base suggests that focusing on nursing would improve patient safety.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
November 01, 2003 - CRM training programs for health care providers
Focusing on information sharing, inquiry, and assertion
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psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
December 14, 2022 - By focusing on developing capacities that enable care teams to respond to emergent problems, resilient … Instead of focusing on adherence to protocols and individual failures, resilient healthcare sees healthcare … Safety-II perspective should begin by looking for what goes right, and the greatest benefit may arise from focusing
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psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
December 14, 2022 - By focusing on developing capacities that enable care teams to respond to emergent problems, resilient … Instead of focusing on adherence to protocols and individual failures, resilient healthcare sees healthcare … Safety-II perspective should begin by looking for what goes right, and the greatest benefit may arise from focusing
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psnet.ahrq.gov/issue/focus-patient-safety
January 23, 2008 - Book/Report
Focus on Patient Safety.
Citation Text:
Focus on Patient Safety. Annu Rev Nurs Res. 2006;24:1-331.
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psnet.ahrq.gov/node/33809/psn-pdf
June 01, 2016 - Working on culture without focusing on burnout and joy and meaning will not give us the results we need … Just focusing on joy and meaning without really looking at culture and leadership is also going to be
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - The second skill is team leadership, focusing on maximizing every team member's potential, which is particularly … TeamSTEPPS provides a helpful framework for creating effective teams focusing on communication, leadership
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - RW: So, if you were trying to accelerate this pace, would you be focusing on creating a business case … RW: When David Brailer became the IT czar, I think he surprised some outsiders by focusing so strongly
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psnet.ahrq.gov/node/33696/psn-pdf
June 01, 2010 - RW: You ended up focusing on cognitive errors and diagnostic errors. … So we turned our M&M rounds
around, focusing on cognitive errors, affective errors, biases, distortions
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - She has directed projects with multiple stakeholders focusing on Medicare Part D Medication Therapy Management … the Director of Medical Education Research and Innovation in the Medical Education Outcomes Center, focusing
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - Although caregiver collaboration is improving and organizations are focusing less on individual blame
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psnet.ahrq.gov/node/33647/psn-pdf
March 01, 2007 - For example, the physician-patient mentioned above tried to engage senior
leadership in focusing the
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psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
February 01, 2014 - working on accelerating patient safety improvement in nursing homes and in ambulatory care—particularly focusing … Our research is focusing on how health IT can be designed and used to improve care, particularly looking … We are constantly focusing on how to make sure that what we do changes policy and practice.