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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - Late Anemia Following Rh Disease in a Newborn
Citation Text:
Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/49547/psn-pdf
October 01, 2007 - Code Blue—Where To?
October 1, 2007
Adams BD. Code Blue—Where To? PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/code-blue-where
The Case
An 80-year-old man with a history of coronary artery disease, hypertension, and schizophrenia was
admitted to an inpatient psychiatry service for hallucinations and anxi…
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - One Bronchoscopy, Two Errors
Citation Text:
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. 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/node/49609/psn-pdf
October 01, 2010 - Dangerous Dialysis
October 1, 2010
Holley JL. Dangerous Dialysis . PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/dangerous-dialysis
Case Objectives
List common errors that occur in dialysis units.
Describe steps that can be taken by dialysis units to prevent these common errors.
Describe the role of the …
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psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/dont-pick-picc
December 01, 2011 - Don't Pick the PICC
Citation Text:
McGill RL. Don't Pick the PICC. 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/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - Are You Mrs. A? An Issue of Identification Over Telephone
Citation Text:
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/bundlingcps.pdf
March 01, 2014 - Bundling Clinical Preventive Services: A Review of Definitions and Concepts from the Literature
Bundling Clinical Preventive Services:
A Review of Definitions and Concepts
from the Literature
Prepared for:
Agency for Healthcare Research and Quality
U.S. Departme…
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www.ahrq.gov/research/publications/ahrq-info-quality-gdlns.html
September 01, 2019 - Guidelines for Ensuring the Quality of Information Disseminated to the Public
C. Agency for Healthcare Research and Quality
Note: Last revised in 2006, these Guidelines also appear on the HHS Web site. AHRQ presents them here with a 2015 Update .
Contents
Agency Mission .
Scope and Applicability …
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psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - Lost in Sign Out and Documentation
Citation Text:
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/returning-home-safely
December 22, 2018 - Returning Home Safely
Citation Text:
Toles M. Returning Home Safely. 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/node/49470/psn-pdf
December 01, 2004 - Discharge Fumbles
December 1, 2004
Forster AJ. Discharge Fumbles. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/discharge-fumbles
Case Objectives
List the types of adverse events that occur at discharge
Identify the characteristics that identify patients at high risk for errors at discharge
Understand th…
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psnet.ahrq.gov/web-mm/urinary-retention-dilemma
March 01, 2013 - Urinary Retention Dilemma
Citation Text:
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - Diffusion of Responsibility Leads to Danger
Citation Text:
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. 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/chemotherapy-extravasation
September 24, 2010 - Chemotherapy Extravasation
Citation Text:
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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www.ahrq.gov/sites/default/files/wysiwyg/topics/IAWG-July-2024-meeting-notes.pdf
January 01, 2024 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare July Meeting Summary
Federal Interagency Workgroup:
Improving Diagnostic Safety and Quality in Healthcare
July Meeting Summary
Workgroup Goal: Established by Senate Report 115-150. The Senate Committee on
Appropriations requ…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-references.html
June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors
References
Previous Page
Table of Contents
Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors
Executive Summary
Introduction
Past…
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psnet.ahrq.gov/web-mm/too-much-too-fast
June 14, 2019 - Too Much, Too Fast
Citation Text:
Tuot D. Too Much, Too Fast. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/chapter5.html
August 01, 2022 - Designing Consumer Reporting Systems for Patient Safety Events
Chapter 5
Previous Page Next Page
Table of Contents
Designing Consumer Reporting Systems for Patient Safety Events
Executive Summary
Chapter 1. Background
Chapter 2. Conceptual Framework and Design
Chapter 3. Description of Metho…
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www.ahrq.gov/teamstepps-program/curriculum/team/tools/index.html
July 01, 2023 - Section 2: Explanation of Key Team Leadership Concepts and Tools
This section contains explanations and illustrations to help you better understand and appreciate the importance of team structure, leadership, and leadership tools. If you teach this content or want additional insights into how the material can b…