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psnet.ahrq.gov/node/47731/psn-pdf
April 27, 2019 - Implementing strategies to identify and mitigate adverse
safety events: a case study with unplanned extubations.
April 27, 2019
Hatch D, Rivard M, Bolton J, et al. Implementing Strategies to Identify and Mitigate Adverse Safety Events:
A Case Study with Unplanned Extubations. Jt Comm J Qual Patient Saf. 2019;45(4):…
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cds.ahrq.gov/sites/default/files/cds/artifact/136331/Bisphosphonates%20Patient%20Handout.pdf
July 18, 2023 - Osteoporosis Patient Handout
Bisphosphonates are the safest choice for most people like you, who have thin
or fragile bones, because this risks of falling and breaking a bone are greater
than the risks of side effects.
Your medication is: _______________________________________
Orally (by mouth)
I.V. (infusion)
D…
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cds.ahrq.gov/sites/default/files/cds/artifact/127731/FallPreventionChairExercises.pdf
July 18, 2023 - Exercise Handouts w/ Drawings
These exercises will help you to improve your balance and get stronger.
Go online to homestrong.net for videos of each exercise and other tips.
Sitting up straight, extend one
leg as straight as you can.
Hold for a count of 3.
Slowly lower the leg down.
Repeat with your other leg.
1.
…
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cds.ahrq.gov/sites/default/files/cds/artifact/66551/Bisphosphonates%20Patient%20Handout.pdf
July 18, 2023 - Osteoporosis Patient Handout
Bisphosphonates are the safest choice for most people like you, who have thin
or fragile bones, because this risks of falling and breaking a bone are greater
than the risks of side effects.
Your medication is: _______________________________________
Orally (by mouth)
I.V. (infusion)
D…
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digital.ahrq.gov/sites/default/files/docs/page/taha-podcast-transcript.pdf
June 16, 2021 - Taha Podcast Transcript
Podcast 2
Factors that Influence Successful Use of a Patient Portal (Dr. Jessica Taha)
Narrator: Welcome to Health IT Spotlight from the Agency for Healthcare Research and Quality.
Web‐based patient portals have the potential to facilitate patient involvement in managing
their health car…
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psnet.ahrq.gov/node/44979/psn-pdf
April 06, 2016 - When a surgeon should just say 'I'm sorry'.
April 6, 2016
Cohen E. CNN. March 24, 2016.
https://psnet.ahrq.gov/issue/when-surgeon-should-just-say-im-sorry
Poor communication regarding medical errors can contribute to patient and family frustration and fear.
Reporting on a case involving disclosure of a wrong-site …
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psnet.ahrq.gov/node/47825/psn-pdf
March 06, 2019 - Diagnostic error as a result of drug-laboratory test
interactions.
March 6, 2019
van Balveren JA, van de Venne WPHGV-, Erdem-Eraslan L, et al. Diagnostic error as a result of drug-
laboratory test interactions. Diagnosis (Berl). 2019;6(1):69-71. doi:10.1515/dx-2018-0098.
https://psnet.ahrq.gov/issue/diagnostic-err…
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psnet.ahrq.gov/node/44149/psn-pdf
June 03, 2015 - Patient safety in home hemodialysis: quality assurance
and serious adverse events in the home setting.
June 3, 2015
Pauly RP, Eastwood DO, Marshall MR. Patient safety in home hemodialysis: quality assurance and serious
adverse events in the home setting. Hemodial Int. 2015;19 Suppl 1:S59-70. doi:10.1111/hdi.12248.
…
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psnet.ahrq.gov/node/72806/psn-pdf
March 03, 2021 - A woman’s laborious search uncovered the probable
cause of her searing abdominal pain. Getting a doctor to
help was much harder.
March 3, 2021
Boodman SG. Washington Post. February 20, 2021.
https://psnet.ahrq.gov/issue/womans-laborious-search-uncovered-probable-cause-her-searing-abdominal-
pain-getting-doct…
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psnet.ahrq.gov/node/41959/psn-pdf
January 16, 2013 - Use of FMEA analysis to reduce risk of errors in
prescribing and administering drugs in paediatric wards:
a quality improvement report.
January 16, 2013
Lago P, Bizzarri G, Scalzotto F, et al. Use of FMEA analysis to reduce risk of errors in prescribing and
administering drugs in paediatric wards: a quality improv…
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psnet.ahrq.gov/node/44424/psn-pdf
August 19, 2015 - Taking patients' narratives about clinicians from anecdote
to science.
August 19, 2015
Schlesinger M, Grob R, Shaller D, et al. Taking Patients' Narratives about Clinicians from Anecdote to
Science. New Engl J Med. 2015;373(7):675-679. doi:10.1056/NEJMsb1502361.
https://psnet.ahrq.gov/issue/taking-patients-narrati…
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psnet.ahrq.gov/node/73889/psn-pdf
September 29, 2021 - Australian hospital leaders on the provision of safe care:
implications for safety I and safety II.
September 29, 2021
Leggat SG, Balding C, Bish M. Perspectives of Australian hospital leaders on the provision of safe care:
implications for safety I and safety II. J Health Org Manag. 2021;35(5):550-560. doi:10.1108…
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psnet.ahrq.gov/node/46292/psn-pdf
August 02, 2017 - Clinical alerts to decrease high-risk medication use in
older adults.
August 2, 2017
Lord-Adem W, Brandt NJ. Clinical Alerts to Decrease High-Risk Medication Use in Older Adults. J Gerontol
Nurs. 2017;43(7):7-12. doi:10.3928/00989134-20170614-04.
https://psnet.ahrq.gov/issue/clinical-alerts-decrease-high-risk-medi…
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psnet.ahrq.gov/node/47503/psn-pdf
October 24, 2018 - I-PASS checklist: a powerful tool for patient handoffs.
October 24, 2018
Peeples L. Pharmacy Practice News. October 10, 2018.
https://psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
Structured handoffs can reduce communication problems that contribute to medical error. This magazine
article re…
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psnet.ahrq.gov/node/43498/psn-pdf
October 06, 2016 - Creating a distraction simulation for safe medication
administration.
October 6, 2016
Thomas CM, McIntosh CE, Allen R. Creating a Distraction Simulation for Safe Medication Administration.
Clin Simul Nurs. 2014;10(8). doi:10.1016/j.ecns.2014.03.004.
https://psnet.ahrq.gov/issue/creating-distraction-simulation-safe…
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psnet.ahrq.gov/node/46289/psn-pdf
January 01, 2021 - Communication training, adverse events, and quality
measures: 2 retrospective database analyses in
Washington State hospitals.
August 9, 2017
Slade IR, Beck SJ, Kramer B, et al. Communication Training, Adverse Events, and Quality Measures: 2
Retrospective Database Analyses in Washington State Hospitals. J Patient …
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psnet.ahrq.gov/node/47979/psn-pdf
May 01, 2019 - Inpatient notes: just what the doctor ordered—checklists
to improve diagnosis.
May 1, 2019
Gupta A, Graber ML. Web Exclusive. Annals for Hospitalists Inpatient Notes - Just What the Doctor
Ordered-Checklists to Improve Diagnosis. Ann Intern Med. 2019;170(8):HO2-HO3. doi:10.7326/M19-0829.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/43186/psn-pdf
May 19, 2014 - ASPEN parenteral nutrition safety consensus
recommendations: translation into practice.
May 19, 2014
Ayers P, Adams S, Boullata JI, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations:
translation into practice. Nutr Clin Pract. 2014;29(3):277-82. doi:10.1177/0884533614531294.
https://psnet.ahr…
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psnet.ahrq.gov/node/45418/psn-pdf
May 09, 2017 - Context-sensitive decision support (infobuttons) in
electronic health records: a systematic review.
May 9, 2017
Cook DA, Teixeira MT, Heale BS, et al. Context-sensitive decision support (infobuttons) in electronic health
records: a systematic review. J Am Med Inform Assoc. 2017;24(2):460-468. doi:10.1093/jamia/ocw1…
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psnet.ahrq.gov/node/45854/psn-pdf
July 12, 2017 - The second victim phenomenon after a clinical error: the
design and evaluation of a website to reduce caregivers'
emotional responses after a clinical error.
July 12, 2017
Mira JJ, Carrillo I, Guilabert M, et al. The Second Victim Phenomenon After a Clinical Error: The Design
and Evaluation of a Website to Reduce …