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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866109/psn-pdf
    June 12, 2024 - Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix. June 12, 2024 Bos K, van der Laan MJ, Groeneweg J, et al. Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix. BMJ Open Qual. 2024…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853236/psn-pdf
    September 06, 2023 - Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study. September 6, 2023 Garcia-Jorda D, Nikitovic D, Gilfoyle E. Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study. Simul Healthc. 2023;18(4…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851923/psn-pdf
    August 02, 2023 - Patient, carer and family experiences of seeking redress and reconciliation following a life-changing event: systematic review of qualitative evidence. August 2, 2023 Shaw L, Lawal HM, Briscoe S, et al. Patient, carer and family experiences of seeking redress and reconciliation following a life?changing event: sys…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851458/psn-pdf
    July 19, 2023 - Improving handoffs in the perioperative environment: a conceptual framework of key theories, system factors, methods, and core interventions to ensure success. July 19, 2023 Starmer AJ, Michael MM, Spector ND, et al. Improving handoffs in the perioperative environment: a conceptual framework of key theories, syste…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851189/psn-pdf
    July 05, 2023 - So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization. July 5, 2023 Conn Busch J, Wu J, Anglade E, et al. So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization. Jt Comm J Qual Patient Saf. 2023;49(8)…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60541/psn-pdf
    May 01, 2013 - Targeted versus universal decolonization to prevent ICU infection. May 1, 2013 Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265. doi:10.1056/nejmoa1207290. https://psnet.ahrq.gov/issue/targeted-versus-universal-decoloni…
  7. psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
    August 01, 2009 - , situational awareness and contingency plans (S), and synthesis by receiver (S). 21 In this case, implementing
  8. psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
    April 01, 2018 - Patient Safety During Hospital Discharge Katherine Liang and Eric Alper, MD | April 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. Rockville…
  9. psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
    March 01, 2011 - In Conversation with…Vineet Arora, MD, MA March 1, 2011  Also Read an Essay Citation Text: In Conversation with…Vineet Arora, MD, MA . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. …
  10. psnet.ahrq.gov/print/pdf/node/867659
    July 10, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Rapid Response Systems Curated Library Primers Rapid Response Systems UC Davis PSNet Editorial Team | September, 15 2024 Rapid response teams represent an intuitively simple concept: when a patient demonstrates signs of imminent clinical de…
  11. psnet.ahrq.gov/perspective/response-getting-root-matter-june-2005
    June 01, 2005 - In response to “Getting to the Root of the Matter” (June 2005) September 1, 2005  View more articles from the same authors. Citation Text: Grondin L, Saint S, Flanders S, et al. In response to “Getting to the Root of the Matter” (June 2005). PSNet [internet]. Rockv…
  12. psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
    August 21, 2024 - They also serve as a valuable rallying point to create a culture of safety on maternity units by implementing
  13. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
    February 01, 2012 - Spotlight Case July 2008 Spotlight Case E-prescribing: E for Error? 1 2 Source and Credits This presentation is based on the February 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33868/psn-pdf
    October 01, 2018 - Safety in the Retail Pharmacy October 1, 2018 Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/safety-retail-pharmacy Perspective There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each year.(1) Many patients interact w…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49839/psn-pdf
    August 01, 2018 - Mixup Beyond the Medication Label August 1, 2018 Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label The Case An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another hospi…
  16. psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
    February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL February 26, 2025 Innovation Contact …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867845/psn-pdf
    February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary February 26, 2025 https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation- summary Summary This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…
  18. psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
    March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy March 10, 2021  Also Read the Essay Citation Text: In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021.In Conversation With... Libby Hoy and Stephen Hoy. PSNet [internet]. Rockville (MD): Agenc…
  19. psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
    March 25, 2025 - These systemic issues can result in inconsistent application of screening protocols and delays in implementing
  20. psnet.ahrq.gov/perspective/suicide-prevention
    March 24, 2025 - These systemic issues can result in inconsistent application of screening protocols and delays in implementing

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