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psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
August 01, 2006 - It seemed to me that this was another systems challengethat we don't have good systems for identifying … Starting with the great work that you all did a few years ago identifying those practices with good
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psnet.ahrq.gov/node/73902/psn-pdf
September 29, 2021 - patients with at least one SEA
risk factor, ESR has been shown to be 100% sensitive and 67% specific for identifying … have poor sensitivity and can miss SEA.13,28
Historically, CT myelography was performed to aid in identifying
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psnet.ahrq.gov/perspective/safety-culture-ems
May 26, 2021 - as an organizational principle, and for many EMS systems, a great deal of focus is still placed on identifying … Crowe, PhD
May 16, 2022
Perspective
Identifying
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - RW: How good are physicians at identifying their own limitations, and from your experience, if a system … December 20, 2023
Identifying trigger concepts to screen emergency department visits
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psnet.ahrq.gov/innovation/team-developed-care-plan-and-ongoing-care-management-social-workers-and-nurse
July 23, 2024 - The team itself can be within the practice or external to it, but the focus needs to be on identifying … Identifying landmark articles for advancing the practice of geriatrics.
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psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
May 01, 2007 - It's simply looking at the environment of care and identifying the sources of risk. … November 30, 2022
Perspective
Identifying Safety Events
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psnet.ahrq.gov/print/pdf/node/866100
August 30, 2023 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Nurse Wellbeing and Patient Safety
Curated Library
Foundations
Keeping Patients Safe: Transforming the Work Environment of Nurses.
Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care
Services. Wash…
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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - SPOTLIGHT CASE
Unintended Consequences of CPOE
Citation Text:
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - SPOTLIGHT CASE
The Perils of Cross Coverage
Citation Text:
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/curated-library/patient-team-member-clinical-care
March 15, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Patient as a Team Member in Clinical Care
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Created By: Lorri Zipperer, Cybraria…
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psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
March 01, 2005 - SPOTLIGHT CASE
CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure
Citation Text:
Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - Also brought to light was the importance of identifying needs related to social determinants of health … And they were responsive to identifying inequities, reaching deeply into communities, and prioritizing
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - And they were responsive to identifying inequities, reaching deeply into communities, and prioritizing … Also brought to light was the importance of identifying needs related to social determinants of health
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psnet.ahrq.gov/node/865660/psn-pdf
April 24, 2024 - Comparing hospital leadership and front-line workers'
perceptions of patient safety culture: an unbalanced
panel study.
April 24, 2024
Forbes J, Arrieta A. Comparing hospital leadership and front-line workers’ perceptions of patient safety
culture: an unbalanced panel study. BMJ Lead. 2024;8(8):335-339. doi:10.113…
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psnet.ahrq.gov/node/60838/psn-pdf
January 01, 2021 - Using the ecological systems theory to understand
black/white disparities in maternal morbidity and mortality
in the United States.
August 26, 2020
Noursi S, Saluja B, Richey L. Using the ecological systems theory to understand black/white disparities in
maternal morbidity and mortality in the United States. J Rac…
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psnet.ahrq.gov/node/37701/psn-pdf
February 22, 2011 - Use of a handheld computer application for voluntary
medication event reporting by inpatient nurses and
physicians.
February 22, 2011
Dollarhide AW, Rutledge T, Weinger MB, et al. Use of a handheld computer application for voluntary
medication event reporting by inpatient nurses and physicians. J Gen Intern Med. 2…
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psnet.ahrq.gov/node/43309/psn-pdf
August 02, 2015 - Wrong-side thoracentesis: lessons learned from root
cause analysis.
August 2, 2015
Miller K, Mims M, Paull DE, et al. Wrong-side thoracentesis: lessons learned from root cause analysis.
JAMA Surg. 2014;149(8):774-9. doi:10.1001/jamasurg.2014.146.
https://psnet.ahrq.gov/issue/wrong-side-thoracentesis-lessons-learne…
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psnet.ahrq.gov/node/61057/psn-pdf
October 28, 2020 - Improving Diagnostic Quality and Safety/Reducing
Diagnostic Error: Measurement Considerations. Final
Report
October 28, 2020
Washington DC; National Quality Forum: October 6, 2020.
https://psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safetyreducing-diagnostic-error-
measurement-considerations
With input…
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psnet.ahrq.gov/node/74099/psn-pdf
January 01, 2022 - Hemodialysis bleeding events and deaths: an 18-year
retrospective analysis of patient safety and root cause
analysis reports in the Veterans Health Administration.
November 24, 2021
Walton E, Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: an 18-year retrospective
analysis of patient safety a…