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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - are both unusual. 4 Although specific to gynecologic surgery, Gostout and colleagues provide a useful framework
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psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
February 26, 2025 - development process described by the guide include the following:
Establishing an organizational framework
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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - Annual Perspective
Patient Safety in the Ambulatory Care Setting
August 5, 2022
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Citation Text:
Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. Rockville (MD): …
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psnet.ahrq.gov/perspective/communication-during-transitions-care
July 10, 2024 - TeamSTEPPS , or Team Strategies and Tools to Enhance Performance and Patient Safety, is an evidence-based framework
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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - Diagnostic Error
January 11, 2022
WebM&M Cases
A framework
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psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
May 31, 2023 - a standard structure embedded into all components of the intervention that serves as an organizing framework
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psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - Duplicate Insulin Order
Citation Text:
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. 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/web-mm/safety-and-quality-long-term-care
January 01, 2016 - Standards such as the Joint Commission National Patient Safety Goals provide a valuable framework for
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psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
April 01, 2008 - Dementia
December 1, 2017
WebM&M Cases
A framework
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - May 1, 2015
Telehealth safety framework: addressing a new frontier in patient safety.
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - A conceptual framework for emergency department-to-inpatient handoff negotiations.
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psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - Advancing Patient Safety Through State Reporting Systems
Jill Rosenthal, MPH | June 1, 2007
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Citation Text:
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - multimethod evaluation of the adaptation, face validity and feasibility of the Manchester Patient Safety Framework
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psnet.ahrq.gov/web-mm/snfs-opening-black-box
August 27, 2012 - and Quality
April 26, 2023
WebM&M Cases
A framework
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psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
August 04, 2021 - Consensus statement provides a framework for health care delivery during the transition period and an
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - Perioperative pharmacology: a framework for perioperative medication safety.
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
March 24, 2025 - there a risk that things will get worse again if we shift back toward a more accountability-focused framework
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - SPOTLIGHT CASE
Out of Sight, Out of Mind: Out-of-Office Test Result Management
Citation Text:
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. 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/empty-bag
June 01, 2018 - and Quality
April 26, 2023
WebM&M Cases
A framework
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psnet.ahrq.gov/web-mm/novel-drug-misuse
September 30, 2010 - A framework for improvement. JAMA. 1999;282:1458-65.[ go to PubMed ] 20. Peck P.