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psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
January 01, 2021 - Spotlight
Spotlight
Two Cases of Retained Vaginal Packing:
When Writing an Order is Not Enough
Source and Credits
• This presentation is based on the April 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Verna Gibbs, MD
o AHRQ W…
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psnet.ahrq.gov/primer/ambulatory-care-safety
December 15, 2024 - Ambulatory Care Safety
Citation Text:
Ambulatory Care Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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…
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psnet.ahrq.gov/node/42819/psn-pdf
October 31, 2014 - Implementing a national program to reduce catheter-
associated urinary tract infection: a quality improvement
collaboration of state hospital associations, academic
medical centers, professional societies, and
governmental agencies.
October 31, 2014
Fakih MG, George C, Edson B, et al. Implementing a national prog…
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psnet.ahrq.gov/node/42895/psn-pdf
December 18, 2014 - National trends in patient safety for four common
conditions, 2005–2011.
December 18, 2014
Wang Y, Eldridge N, Metersky M, et al. National trends in patient safety for four common conditions, 2005-
2011. N Engl J Med. 2014;370(4):341-51. doi:10.1056/NEJMsa1300991.
https://psnet.ahrq.gov/issue/national-trends-patie…
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psnet.ahrq.gov/node/46932/psn-pdf
April 22, 2018 - Hospital Survey on Patient Safety Culture: 2018 User
Database Report.
April 22, 2018
Famolaro T, Yount N, Hare, R, et al. Rockville, MD: Agency for Healthcare Research and Quality; March
2018. AHRQ Publication No. 18-0025-EF.
https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2018-user-database-re…
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psnet.ahrq.gov/node/39583/psn-pdf
October 30, 2010 - The harm susceptibility model: a method to prioritise
risks identified in patient safety reporting systems.
October 30, 2010
Pham JC, Colantuoni E, Dominici F, et al. The harm susceptibility model: a method to prioritise risks
identified in patient safety reporting systems. Qual Saf Health Care. 2010;19(5):440-5.
…
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psnet.ahrq.gov/node/40785/psn-pdf
May 04, 2012 - A framework for evaluating the appropriateness of clinical
decision support alerts and responses.
May 4, 2012
McCoy AB, Waitman LR, Lewis JB, et al. A framework for evaluating the appropriateness of clinical
decision support alerts and responses. J Am Med Inform Assoc. 2012;19(3):346-52. doi:10.1136/amiajnl-
2011-…
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psnet.ahrq.gov/node/42118/psn-pdf
March 20, 2013 - Simulation exercises as a patient safety strategy: a
systematic review.
March 20, 2013
Schmidt E, Goldhaber-Fiebert SN, Ho LA, et al. Simulation exercises as a patient safety strategy: a
systematic review. Ann Intern Med. 2013;158(5 Pt 2):426-32. doi:10.7326/0003-4819-158-5-201303051-
00010.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/46774/psn-pdf
April 12, 2019 - Association between handover of anesthesia care and
adverse postoperative outcomes among patients
undergoing major surgery.
April 12, 2019
Jones PM, Cherry RA, Allen BN, et al. Association Between Handover of Anesthesia Care and Adverse
Postoperative Outcomes Among Patients Undergoing Major Surgery. JAMA. 2018;319…
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psnet.ahrq.gov/node/40893/psn-pdf
November 02, 2011 - Systematic review of safety checklists for use by medical
care teams in acute hospital settings—limited evidence of
effectiveness.
November 2, 2011
Ko HCH, Turner TJ, Finnigan MA. Systematic review of safety checklists for use by medical care teams in
acute hospital settings--limited evidence of effectiveness. BMC…
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psnet.ahrq.gov/node/46110/psn-pdf
January 01, 2019 - Examination of the relationship between management and
clinician perception of patient safety climate and patient
satisfaction.
December 21, 2018
Mazurenko O, Richter J, Kazley AS, et al. Examination of the relationship between management and
clinician perception of patient safety climate and patient satisfaction.…
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psnet.ahrq.gov/node/43063/psn-pdf
May 01, 2015 - More Than 1,000 Preventable Deaths a Day Is Too Many:
The Need to Improve Patient Safety.
May 1, 2015
Hearing Before the Subcommittee on Primary Health and Aging, 113th Cong (July 17, 2014).
https://psnet.ahrq.gov/issue/more-1000-preventable-deaths-day-too-many-need-improve-patient-safety
A group of patient safety…
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psnet.ahrq.gov/node/44034/psn-pdf
January 19, 2016 - Surgical checklist implementation project: the impact of
variable WHO checklist compliance on risk-adjusted
clinical outcomes after national implementation: a
longitudinal study.
January 19, 2016
Mayer EK, Sevdalis N, Rout S, et al. Surgical Checklist Implementation Project: The Impact of Variable
WHO Checklist C…
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces
Hospitalizations Among Nursing Home Residents
July 28, 2021
https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-
home-residents
Summary
The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - Debriefing for Clinical Learning
November 18, 2021
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/debriefing-clinical-learning
Updated in September 2021. Originally published in December 2011 by researchers at the University of
California, S…
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psnet.ahrq.gov/node/845472/psn-pdf
March 15, 2023 - Another potential
way patient safety could be improved is with medication compliance, maybe by picking
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - Care Transitions
Sunil Kripalani, MD, MSc | December 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Kripalani S. Care Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depart…
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psnet.ahrq.gov/issue/development-national-reporting-and-learning-system-england-and-wales-2001-2005
September 14, 2022 - Commentary
The development of the National Reporting and Learning System in England and Wales, 2001-2005.
Citation Text:
Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and Wales, 2001–2005. Med J Aust. 2019;184(S10) (S10):s65-s68. doi:1…
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psnet.ahrq.gov/issue/cognitive-bias-clinical-medicine
February 20, 2019 - Commentary
Classic
Cognitive bias in clinical medicine.
Citation Text:
O'Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicians Edinb. 2018;48(3):225-232. doi:10.4997/JRCPE.2018.306.
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DOI Google Sch…
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psnet.ahrq.gov/issue/professionalism-medicine-results-national-survey-physicians
February 17, 2011 - Study
Classic
Professionalism in medicine: results of a national survey of physicians.
Citation Text:
Campbell EG, Regan S, Gruen RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007;147(11):795-802.
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