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digital.ahrq.gov/ahrq-funded-projects/anesthesiology-control-tower-feedback-alerts-supplement-treatment-actfast
January 01, 2023 - the nearby airplanes and helping them to coordinate their activity, and prioritizing what needs to happen
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psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - risky as a person with a recent hip fracture unattended in a bathroom: both are accidents waiting to happen
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psnet.ahrq.gov/web-mm/saved-ecmo
May 05, 2017 - was appropriate and was likely the safest option, the anesthesia team failed to plan for what would happen
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - Every patient
is different and things happen in the hospitalization, so to get the acute situation under
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psnet.ahrq.gov/node/49591/psn-pdf
October 01, 2009 - Difficult Encounters: A CMO and CNO Respond
October 1, 2009
Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
Case Objectives
Appreciate the risk of disruptive behavior and understand institutional respons…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/program-dev-facilitator-guide.docx
June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use
1
Developing an Antibiotic Stewardship Program
Long-Term Care
Slide Title and Commentary
Slide Number and Slide
Developing an Antibiotic Stewardship Program
Long-Term Care
SAY:
Hello and welcome to the presentation, “Developing an Antibiotic Stewardship Prog…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-event-reporting_revised.docx
April 01, 2022 - CAUTI Event Reporting Tool
CLABSI Event Report Tool: Data for Event Analysis
This event report template is designed to be used as a guide through the initial investigation for a defects analysis where the primary goal is to learn what happened and factors that may have contributed to the central line-associated blo…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module3/mod3-facguide.html
March 01, 2017 - because they will fear punishment, and processes may not change and the same mistakes will continue to happen
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-5-implementation-guide.pdf
June 02, 2025 - TAKEheart Automatic Referral Implementation Guide - Module 5
Module 5 Implementation Guide:
Building and Implementing a Successful Automatic Cardiac Rehab Referral System
Purpose and Overview
This implementation guide is designed to help you think through the steps you will need to address in
designing and i…
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www.ahrq.gov/research/findings/final-reports/stpra/stpraapd2.html
April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Appendix D, Table D2
Previous Page Next Page
Table of Contents
Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Executive Summary
Chapter 1. Introduction
Chapter 2. ST-PRA Devel…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/training-tools-slideset.pptx
May 01, 2017 - When might this happen?
45 Million Lives Campaign.
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psnet.ahrq.gov/node/867357/psn-pdf
December 18, 2024 - Hypoxemia after Emergency Intubation
December 18, 2024
Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
The Case
A 19-month-old child was brought to the emergency department (ED) via ambulance after drowning in a
p…
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psnet.ahrq.gov/node/49813/psn-pdf
January 01, 2018 - How did this
happen?
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psnet.ahrq.gov/node/33873/psn-pdf
February 01, 2019 - In Conversation With… Susan E. Skochelak, MD, PhD
February 1, 2019
In Conversation With… Susan E. Skochelak, MD, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
Editor's note: Dr. Skochelak is the Group Vice President for Medical Education at the American Medica…
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psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
March 24, 2019 - Hypoxemia after Emergency Intubation
Citation Text:
Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 X…
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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
September 25, 2024 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected
Citation Text:
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - They should never happen in the provision of health care. 4 Per the Centers for Medicare and Medicaid
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psnet.ahrq.gov/issue/when-surgeon-too-old-operate
February 12, 2016 - Newspaper/Magazine Article
When is the surgeon too old to operate?
Citation Text:
When is the surgeon too old to operate? Span P. New York Times. February 1, 2019.
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psnet.ahrq.gov/issue/patient-safety-article-collection
December 19, 2012 - Multi-use Website
Patient Safety Article Collection.
Citation Text:
Patient Safety Article Collection. American Patient Rights Association. 2012-2022.
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psnet.ahrq.gov/issue/mistaking-error
July 06, 2011 - Book/Report
Mistaking error.
Citation Text:
Mistaking error. Cook RI, Woods DD. Chapter in: Youngberg BJ, Hatlie, MJ, ed. Patient Safety Handbook, Sudbury, MA: Jones and Bartlett; 2004.
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