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psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical
Record Causing an Accidental Medication Overdose
October 31, 2023
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an
Accidental Medication Overdose. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/weight-and-…
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www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
January 01, 2024 - Final Progress Report: How Do Consumers View the Risks of Medical Errors?
FINAL REPORT
Title of Project: How Do Consumers View the Risks
of Medical Errors?
Principal Investigator: Ellen Peters
Team Member: Paul Slovic
Organization: Decision Research
Inclusive Dates of Project: 09/01/2001 – 08/31/2003
Federal …
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psnet.ahrq.gov/web-mm/standard-deviations
January 01, 2006 - SPOTLIGHT CASE
Standard Deviations
Citation Text:
Sabin JE. Standard Deviations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - Near Miss with Bedside Medications
November 1, 2011
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications
Case Objectives
Understanding the definition of near miss—also known as close call.
Appreciate the importance of close calls in reducin…
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - SPOTLIGHT CASE
The ECG Is Not Normal
Citation Text:
Zuger A. The ECG Is Not Normal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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psnet.ahrq.gov/node/33738/psn-pdf
December 01, 2012 - In Conversation With... John G. Reiling, PhD
December 1, 2012
In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
Editor's note: John G. Reiling, PhD, is president and CEO of Safe by Design. Dr. Reiling consults with
hospitals and…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/039-mrsa-surveillance-slides.pptx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
AHRQ Safety Program for MRSA Prevention
MRSA Surveillance
ICU & Non-ICU
AHRQ Pub. No. 25-0007
October 2024
AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU
MRSA Surveillance
1
Educational Objectives
Describe both active and passive approaches to surveillance of methic…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/040-mrsa-surveillance-notes.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
MRSA Surveillance
ICU & Non-ICU
Slide Title and Commentary
Slide Number and Slide
MRSA Surveillance
SAY:
Welcome to this presentation on MRSA Surveillance, which will explain how various approaches to MRSA surveillance help to prevent transmission of MRSA in intensive care u…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/child-hcahps-survey-english.pdf
May 12, 2016 - Child Hospital Survey
CAHPS® Hospital Survey
Version: Child Version
Language: English
File name: Child_HCAHPS_English_Survey_954a.docx
Last updated: May 12, 2016
Instructions for Front Cover
• Replace the cover of this document with your own front cover. Include a user-friendly title
and your own logo.
•…
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psnet.ahrq.gov/node/49864/psn-pdf
June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You
in Training About Feedback and Burnout
June 1, 2019
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]. 2019.
https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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www.ahrq.gov/sites/default/files/2025-04/graber-report.pdf
January 01, 2025 - Final Progress Report: Diagnostic Error in Medicine Conference
Final Progress Report
Grant Number 1R13HS018321-01
Project Period 8/1/2009 - 1/31/2010
Conference: Diagnostic Error In Medicine
PI: Mark L. Graber, MD
SUMMARY: This grant was used in support of “Diagnostic Error in Medicine – 2009,” a 2-day confer…
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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - Check the Wristband
July 1, 2003
Rosenthal M. Check the Wristband. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/check-wristband
The Case
The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the
impending surgery. The patient spoke English and appeared to be of aver…
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psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - The "Customer" Is Always Right
February 1, 2007
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/customer-always-right
Case Objectives
Understand the importance of identifying a patient's agenda.
Appreciate the factors that contribute to unmet patient expectations.
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-about-cusp-facilitator-guide.pdf
May 01, 2017 - Learn About the Comprehensive Unit-Based Safety Program for Perinatal Safety
AHRQ Safety Program for Perinatal Care
Learn About the Comprehensive Unit-Based Safety Program for Perinatal Safety
AHRQ Publication No. 17-0003-1-EF
May 2017
SAY:
This module introduces the comprehensive
unit-based safety program, …
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/implementation-guides/implementation-guide1/impguide1step3.html
March 01, 2019 - Step 3: Build the Stakeholder Group Structure
Implementation Guide Number 1
This Implementation Guide includes suggested steps and tips for implementing initiatives for improving child health care quality from the CMS-funded national evaluation of the Children’s Health Insurance Program Reauthorization Act of…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
January 01, 2019 - Spotlight
Spotlight
Mistaken Attribution, Diagnostic Misstep
*
Source and Credits
This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD
…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/microbiologic-specimens-facilitator-guide.docx
June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use
1
Appropriate Collection of Microbiologic Specimens
Long-Term Care
Slide Title and Commentary
Slide Number and Slide
Appropriate Collection of Microbiologic Specimens
Long-Term Care
SAY:
Welcome to this presentation, titled, “Appropriate Collection of Microbiol…
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psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Transfer Troubles
June 1, 2012
Hains IM. Transfer Troubles. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfer-troubles
Case Objectives
Recognize that transfer of patients between hospitals is common.
Understand the frequency of errors and adverse events in the transfer of patients between hospitals.
…