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psnet.ahrq.gov/node/49828/psn-pdf
May 01, 2018 - Out of Sight, Out of Mind: Out-of-Office Test Result
Management
May 1, 2018
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
Case Objectives
Recognize the general responsibilities of…
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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - Applying the framework in the analysis of this case
reveals a substantial number of failures and areas
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psnet.ahrq.gov/node/33710/psn-pdf
May 01, 2011 - 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/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Patient Safety Innovations
The I-READI Quality and Safety Framework
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www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide5.html
October 01, 2022 - The Framework for Improvement
Chapter 2. Analyze Care Delivery
Chapter 3.
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digital.ahrq.gov/sites/default/files/docs/page/AppendixB.pdf
February 01, 2012 - ● Adult Learning Theory: a theoretical framework for helping adults learn new skills or
information
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - Annual Perspective
Impact of System Failures on Healthcare Workers
George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD
| March 21, 2023
View more articles from the same authors.
Citation Text:
Zangaro G, Van CM, Mossburg S. Imp…
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www.ahrq.gov/pqmp/implementation-qi/toolkit/antipsychotic/other-resources.html
September 01, 2021 - Step 3: Engage Youth and Family
Journal Article: Patient And Family Engagement: A Framework For
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - Reason's model, the Human Factors Analysis and Classification System (HFACS) provides a comprehensive framework
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Failure to Rescue the Mother
Citation Text:
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote…
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psnet.ahrq.gov/node/60745/psn-pdf
October 01, 2020 - Perioperative pharmacology: a framework for perioperative
medication safety.
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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - Patient Safety Innovations
The I-READI Quality and Safety Framework
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Diagnostic Error
January 11, 2022
WebM&M Cases
A framework
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide5.html
October 01, 2022 - The Framework for Improvement
Chapter 2. Analyze Care Delivery
Chapter 3.
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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - February 17, 2017
A framework to assess patient-reported adverse outcomes arising during
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psnet.ahrq.gov/web-mm/code-status-confusion
September 01, 2006 - February 17, 2017
A World Health Organization field trial assessing a proposed ICD-11 framework
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/misuse-prescription-protocol.pdf
September 13, 2024 - Judging the quality of evidence in reviews of
prognostic factor research: adapting the GRADE framework
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www.ahrq.gov/patient-safety/reports/hotline/intro1.html
May 01, 2016 - The team worked with the two organizations to clarify the legal and regulatory framework for operation
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - Patient Safety Innovations
The I-READI Quality and Safety Framework