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psnet.ahrq.gov/primer/radiation-safety
September 15, 2024 - November 9, 2022
Identifying patients whose symptoms are underrecognized during treatment
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psnet.ahrq.gov/node/33874/psn-pdf
February 01, 2019 - Aligning education with
health care transformation: identifying a shared mental model of "new" faculty
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psnet.ahrq.gov/node/49631/psn-pdf
July 01, 2011 - of low adherence for individuals, this may not be feasible as there
are no validated approaches to identifying
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psnet.ahrq.gov/node/49832/psn-pdf
June 01, 2018 - In addition, the physician providing nighttime coverage may not have received a detailed
handoff identifying
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psnet.ahrq.gov/node/49812/psn-pdf
November 01, 2017 - Specimen reconciliation alerts laboratory staff to pending specimens and
diminishes the risk of loss by identifying
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - SPOTLIGHT CASE
Another Fall
Citation Text:
Bogardus SG. Another Fall. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - Another Fall
April 1, 2003
Bogardus SG. Another Fall. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/another-fall
Case Objectives
List risk factors for falls in hospitalized patients
Understand appropriate use of restraints
Identify system issues contributing to falls in hospitalized patients
Case & Comm…
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near-
Miss Wrong Transfusion Event
January 29, 2020
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
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psnet.ahrq.gov/node/865610/psn-pdf
April 24, 2024 - Suicide Prevention in an Emergency Department
Population: ED-SAFE
April 24, 2024
https://psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
Summary
Suicide is the 12th leading cause of death in the United States, and the 3rd leading cause of death for
people ages 15-24.1 More tha…
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - Identifying and treating those with opioid use disorders must also be a priority. … There's no way of identifying who is not going to be harmed.
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psnet.ahrq.gov/issue/patient-safety-incident-reporting-and-learning-guidelines-implemented-health-care
January 08, 2025 - Review
Patient safety incident reporting and learning guidelines implemented by health care professionals in specialized care units: scoping review.
Citation Text:
Gqaleni TM, Mkhize SW, Chironda G. Patient safety incident reporting and learning guidelines implemented by health care prof…
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psnet.ahrq.gov/issue/diagnostic-error-medicine-0
November 28, 2018 - Special or Theme Issue
Diagnostic Error in Medicine.
Citation Text:
Diagnostic Error in Medicine. Singh H, ed. BMJ Qual Saf. 2013;22(suppl 2):ii1-ii72.
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psnet.ahrq.gov/issue/communicating-critical-test-results
May 24, 2006 - Special or Theme Issue
Communicating Critical Test Results.
Citation Text:
Communicating Critical Test Results. Schiff GD, Bates DW, Leape LL, eds. Jt Comm J Qual Patient Saf. 2005;31(2):62-119.
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psnet.ahrq.gov/issue/health-services-safety-investigations-body
February 04, 2015 - Multi-use Website
Health Services Safety Investigations Body.
Citation Text:
Health Services Safety Investigations Body. Lytchett House, 13 Freeland Park, Wareham Road, Poole, Dorset, BH16 6FA.
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…
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psnet.ahrq.gov/issue/draft-guidelines-safe-communication-electronic-medication-information
September 30, 2020 - Newspaper/Magazine Article
Draft Guidelines for the Safe Communication of Electronic Medication Information.
Citation Text:
Draft Guidelines for the Safe Communication of Electronic Medication Information. Institute for Safe Medication Practices. Acute Care Edition. August 27, 2015;2;1-3…
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psnet.ahrq.gov/issue/dangerous-doses
April 27, 2005 - Newspaper/Magazine Article
Dangerous doses.
Citation Text:
Dangerous doses. Roe S, King K. Chicago Tribune. February 10–13, 2016.
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psnet.ahrq.gov/issue/developing-common-language-evaluation-questions-quality-and-safety-improvement
September 27, 2016 - Review
Developing a common language for evaluation questions in quality and safety improvement.
Citation Text:
Developing a common language for evaluation questions in quality and safety improvement. Lambert MF; Shearer H.
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - Planning and Development Process
Key steps in planning and implementing the innovation include: Identifying
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psnet.ahrq.gov/primer/individual-clinician-performance-issues
March 15, 2025 - State licensing boards are tasked with identifying physicians who pose a threat to patient safety and
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psnet.ahrq.gov/web-mm/preventable-transfer-hospital
March 31, 2022 - time-sensitive sharing of information and frank discussions with patients and caregivers;
difficulties in identifying