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psnet.ahrq.gov/web-mm/caution-interrupted
October 01, 2016 - Caution, Interrupted
Citation Text:
Wears RL. Caution, Interrupted. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout
Citation Text:
Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - SPOTLIGHT CASE
Near Miss with Bedside Medications
Citation Text:
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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www.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-10.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Appendix, Sample Staff Flier to Announce Rollout/Implementation of Medication Reconciliation Process
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Table of Contents
Medications at Transitions and Clinical Handoffs (MATCH) Toolk…
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - SPOTLIGHT CASE
Intubation Mishap
Citation Text:
Weinger MB, Blike G. Intubation Mishap. 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/issue/who-do-hospital-physicians-and-nurses-go-advice-about-medications-social-network-analysis-and
May 22, 2013 - Study
Who do hospital physicians and nurses go to for advice about medications? A social network analysis and examination of prescribing error rates.
Citation Text:
Creswick N, Westbrook JI. Who Do Hospital Physicians and Nurses Go to for Advice About Medications? A Social Network Analys…
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psnet.ahrq.gov/issue/go-between-study-simulation-study-comparing-traffic-lights-and-sbar-tools-means-communication
March 01, 2023 - Study
The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'SBAR' tools as a means of communication between anaesthetic staff.
Citation Text:
MacDougall-Davis SR, Kettley L, Cook TM. The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'S…
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www.ahrq.gov/patient-safety/settings/hospital/match/chapter-4.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Chapter 4. Developing and Pilot Testing Change: Implementing the Medication Reconciliation Process
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/postdiscalldoc.pdf
April 07, 2025 - 1
Postdischarge Followup Phone Call Documentation Form
Patient name: __________________________________________________________________
Caregiver(s) name(s): ____________________________________________________________
Relationship to patient: __________________________________________________________
Notes:…
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digital.ahrq.gov/sites/default/files/docs/survey/parents-vaccination-decision-for-child.pdf
June 16, 2021 - Survey About Parents’ Vaccination Decision for their Child
Survey About Parents’ Vaccination Decision for
their Child
Kaiser Foundation Research Institute, Oakland, California
This is a questionnaire designe…
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digital.ahrq.gov/sites/default/files/docs/page/sustainability-partnerships-and-teamwork-in-health-it-implementation.pdf
December 01, 2012 - his colleagues indicated, “We learned more about our own error reporting by listening to what was
going … “We could have said, ‘We’re going to have a portal, you
all use it,’ and it wouldn’t have worked. … ‘How are
we going to go about this?’ … the individual level, and hired a new trainer who would engage
individuals in the redesign, “He is going … personnel needs have been planned for.
1-not at all, 5-completely
Notes:
Project Assessment
On-going
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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - "Superficial" Report Leads to "Deep" Problem
Citation Text:
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. 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/lethal-vertigo
September 20, 2011 - Lethal Vertigo
Citation Text:
Furman JM. Lethal Vertigo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - SPOTLIGHT CASE
Low on the Totem Pole
Citation Text:
Wachter R. Low on the Totem Pole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/code-status-confusion
September 01, 2006 - SPOTLIGHT CASE
Code Status Confusion
Citation Text:
Lo B, Tulsky JA. Code Status Confusion. 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/inside-time-out
March 01, 2004 - The Inside of a Time Out
Citation Text:
Feldman DL. The Inside of a Time Out. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - mistake could all potentially negatively affect HCWs’ psychological safety and suppress employee voice going
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - A nurse documented his pain going from 8 to 10 before the
morphine, then back to 8 afterwards.
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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
September 27, 2023 - March 31, 2022
‘You’re going to release him when he was hurting himself?’
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - effort was made in this case to ensure that the patient received the discharge medications prior to going