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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - study 7 ), although systematic reviews have not shown convincing evidence to support the use of one form
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psnet.ahrq.gov/web-mm/failure-latch
November 27, 2012 - • Lactation support in the form of evidence-based protocols, education for health care providers
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - Slow Down: Right Drug, Wrong Formulation
Citation Text:
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/emergency-error
January 18, 2013 - Patients undergoing emergency laparotomy form the highest risk group of all emergency surgical admissions
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - SPOTLIGHT CASE
Harm From Alarm Fatigue
Citation Text:
Pelter MM, Drew BJ. Harm From Alarm Fatigue. 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/inside-time-out
March 01, 2004 - Most hospital charts contain a special form, which includes all components of the Universal Protocol
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - SPOTLIGHT CASE
Signout Fallout
Citation Text:
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors
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March 3, 2021
Innovation…
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - sedation and patients may need airway intervention if deep sedation is achieved. 9 No matter which form
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psnet.ahrq.gov/web-mm/transfusion-overload
September 23, 2020 - group education, guidelines, audit with feedback, audit with approval, or the implementation of a new form
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psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
July 23, 2024 - Suicide Prevention in an Emergency Department Population: ED-SAFE
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April 24, 2024
View more articles from the same authors.
Innovation
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psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
April 17, 2025 - The authors provide a summary of their safe practice recommendations and share their reconciliation form
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - disorder, with features of both (prevalence, 25%).( 16 ) This patient appeared to have the hyperactive form
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psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
April 26, 2023 - Annual Perspective
Technology as a Tool for Improving Patient Safety
A Jay Holmgren, Susan McBride,Bryan Gale, Sarah Mossburg
| March 29, 2023
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Citation Text:
Holmgren AJ, McBride S, Gale B, et al. Technology as a …
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
February 22, 2023 - Diagnostic Process
Unconscious thinking in clinical decision making may contribute to misdiagnosis in the form
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psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - They refused to accept digital records (in interoperable form) or even as PDF via email.
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - Check ALL that apply: Preanalytic error ___ Consent form missing (e.g., HIV) ___ Requisition incorrect
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - The most commonly sought form of support was a respected peer with whom to discuss the details of what
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - change is based on the placement approach (percutaneous or surgical), the patient's ability to heal and form
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - that when approaching a patient with chest pain, clinicians should pay careful attention to the ECG, form