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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - Fall prevention is a three-step process: (i) screening for fall risk, (ii) identifying interventions
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - Reduce Medication Errors
A complete, accurate, and current medication list is a critical tool for identifying
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - In contrast, Type 2 thinking is more deliberate and requires identifying
features from a diagnostic
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psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - compartment should prompt investigation
for possible compartment syndrome
29
Compartment Syndrome (7)
• Identifying
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - Developing a more robust outpatient or home-based palliative team can
improve continuity of care by identifying
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - Developing a more robust
outpatient or home-based palliative team can improve continuity of care by identifying
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psnet.ahrq.gov/node/50768/psn-pdf
December 27, 2019 - When I
came to AHRQ, my boss had done some work on identifying non-financial barriers to care, one of
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - In contrast, Type 2 thinking is more deliberate and requires identifying features from a diagnostic category
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psnet.ahrq.gov/node/45608/psn-pdf
October 27, 2016 - Errors, omissions, and outliers in hourly vital signs
measurements in intensive care.
October 27, 2016
Maslove DM, Dubin JA, Shrivats A, et al. Errors, Omissions, and Outliers in Hourly Vital Signs
Measurements in Intensive Care. Crit Care Med. 2016;44(11):e1021-e1030.
https://psnet.ahrq.gov/issue/errors-omissions…
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psnet.ahrq.gov/node/866353/psn-pdf
July 24, 2024 - A clinical pharmacist-led transitions of care program for
veterans with two planned care transitions (hospital to
skilled care and skilled care to home) amid the COVID-19
pandemic.
July 24, 2024
Scannell GA, Bevan DJ, Cowan A, et al. A clinical pharmacist-led transitions of care program for veterans
with two plan…
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psnet.ahrq.gov/node/36909/psn-pdf
January 05, 2017 - Medical team training: applying crew resource
management in the Veterans Health Administration.
January 5, 2017
Dunn EJ, Mills PD, Neily J, et al. Medical team training: applying crew resource management in the
Veterans Health Administration. Jt Comm J Qual Patient Saf. 2007;33(6):317-325.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/867750/psn-pdf
March 12, 2025 - Doing 'detective work' to find a cancer: how are non-
specific symptom pathways for cancer investigation
organised, and what are the implications for safety and
quality of care? A multisite qualitative approach.
March 12, 2025
Black GB, Nicholson BD, Moreland J-A, et al. Doing ‘detective work’ to find a cancer: ho…
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psnet.ahrq.gov/node/73156/psn-pdf
April 21, 2021 - Increasing naloxone prescribing in the emergency
department through education and electronic medical
record work-aids.
April 21, 2021
Funke M, Kaplan MC, Glover H, et al. Increasing naloxone prescribing in the emergency department
through education and electronic medical record work-aids. Jt Comm J Qual Patient Sa…
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psnet.ahrq.gov/node/39392/psn-pdf
September 20, 2011 - Effect of point-of-care computer reminders on physician
behaviour: a systematic review.
September 20, 2011
Shojania KG, Jennings A, Mayhew A, et al. Effect of point-of-care computer reminders on physician
behaviour: a systematic review. CMAJ. 2010;182(5):E216-25. doi:10.1503/cmaj.090578.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/47705/psn-pdf
June 19, 2019 - Decisions and repercussions of second victim
experiences for mothers in medicine (SAVE DR MoM).
June 19, 2019
Gupta K, Lisker S, Rivadeneira NA, et al. Decisions and repercussions of second victim experiences for
mothers in medicine (SAVE DR MoM). BMJ Qual Saf. 2019;28(7):564-573. doi:10.1136/bmjqs-2018-
008372.
…
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psnet.ahrq.gov/node/47723/psn-pdf
January 01, 2020 - Psychological and psychosomatic symptoms of second
victims of adverse events: a systematic review and meta-
analysis.
May 1, 2019
Busch IM, Moretti F, Purgato M, et al. Psychological and Psychosomatic Symptoms of Second Victims of
Adverse Events. J Patient Saf. 2020;16(2):e61-e74. doi:10.1097/pts.0000000000000589.…
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psnet.ahrq.gov/node/73397/psn-pdf
June 16, 2021 - Safe opioid prescribing: a prognostic machine learning
approach to predicting 30-day risk after an opioid
dispensation in Alberta, Canada.
June 16, 2021
Sharma V, Kulkarni V, Eurich DT, et al. Safe opioid prescribing: a prognostic machine learning approach to
predicting 30-day risk after an opioid dispensation in …
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psnet.ahrq.gov/node/45598/psn-pdf
November 23, 2016 - AHRQ Nursing Home Survey on Patient Safety Culture:
2016 User Comparative Database Report.
November 23, 2016
Famolaro T, Yount ND, Greene, K, Hare R, Thorton S, Sorra J. Rockville, MD: Agency for Healthcare
Research and Quality; October 2016. AHRQ Publication No. 17-0004-EF.
https://psnet.ahrq.gov/issue/ahrq-nursi…
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psnet.ahrq.gov/node/45666/psn-pdf
April 24, 2018 - The relationship between professional burnout and
quality and safety in healthcare: a meta-analysis.
April 24, 2018
Salyers MP, Bonfils KA, Luther L, et al. The Relationship Between Professional Burnout and Quality and
Safety in Healthcare: A Meta-Analysis. J Gen Intern Care. 2017;32(4):475-482. doi:10.1007/s11606-…
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psnet.ahrq.gov/node/866906/psn-pdf
October 09, 2024 - Potential harms resulting from patient–clinician real-time
clinical encounters using video-based telehealth: a
making healthcare safer rapid evidence review.
October 9, 2024
Rosen MA, Stewart CM, Kharrazi H, et al. Potential harms resulting from patient–clinician real-time clinical
encounters using video-based tel…