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psnet.ahrq.gov/node/867206/psn-pdf
December 18, 2024 - Davis, Health must ensure
balance, independence and objectivity in all its CME activities to promote improvements
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psnet.ahrq.gov/primer/patient-engagement-and-safety
August 30, 2023 - Patient Engagement and Safety
Citation Text:
Patient Engagement and Safety. 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/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
September 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
Citation Text:
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. 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/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
“This is the wrong patient’s blood!”:
Evaluating a Near-Miss Wrong
Transfusion Event
Source and Credits
• This presentation is based on the January 2020 AHRQ WebM&M
Spotlight Case
• Commentary by: Sarah Barnhard MD
o Medical Director of Transfusion Services at UC-Davis Health
o Editors in …
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psnet.ahrq.gov/issue/safe-and-appropriate-use-insulin-and-other-antihyperglycemic-agents-hospital
April 18, 2016 - Review
Safe and appropriate use of insulin and other antihyperglycemic agents in hospital.
Citation Text:
Cornish W. Safe and appropriate use of insulin and other antihyperglycemic agents in hospital. Can J Diabetes. 2014;38(2):94-100. doi:10.1016/j.jcjd.2014.01.002.
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psnet.ahrq.gov/issue/adverse-event-screening-tool-based-routinely-collected-hospital-acquired-diagnoses
July 23, 2008 - Study
An adverse event screening tool based on routinely collected hospital-acquired diagnoses.
Citation Text:
Brand CA, Tropea J, Gorelik A, et al. An adverse event screening tool based on routinely collected hospital-acquired diagnoses. Int J Qual Health Care. 2012;24(3):266-78. doi:10…
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psnet.ahrq.gov/issue/patterns-errors-contributing-trauma-mortality-lessons-learned-2594-deaths
March 24, 2021 - Study
Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths.
Citation Text:
Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of Errors Contributing to Trauma Mortality. Transactions of the .. Meeting of the American Surgical Association. 2006;124. d…
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psnet.ahrq.gov/issue/reporting-patient-safety-incidents-first-experiences-chiropractic-reporting-and-learning
September 11, 2024 - Study
The reporting of patient safety incidents—first experiences with the chiropractic reporting and learning system (CRLS): a pilot study.
Citation Text:
Thiel H, Bolton J. The reporting of patient safety incidents—first experiences with the chiropractic reporting and learning syst…
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psnet.ahrq.gov/issue/simulation-and-diagnostic-process-pilot-study-trauma-and-rapid-response-teams
July 16, 2015 - Study
Simulation and the diagnostic process: a pilot study of trauma and rapid response teams.
Citation Text:
Juriga LL, Murray DJ, Boulet JR, et al. Simulation and the diagnostic process: a pilot study of trauma and rapid response teams. Diagnosis (Berl). 2017;4(4):241-249. doi:10.1515/…
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psnet.ahrq.gov/issue/supporting-perioperative-safety-during-disaster-through-clinical-crisis-education
July 05, 2017 - Commentary
Supporting perioperative safety during a disaster through clinical crisis education.
Citation Text:
Kirkman A, Tripp H, Ward L, et al. Supporting perioperative safety during a disaster through clinical crisis education. AORN J. 2024;120(4):226-237. doi:10.1002/aorn.14217.
Co…
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psnet.ahrq.gov/issue/patient-safety-curriculum-graduate-medical-education-results-needs-assessment-educators-and
May 01, 2014 - Study
A patient safety curriculum for graduate medical education: results from a needs assessment of educators and patient safety experts.
Citation Text:
Varkey P, Karlapudi S, Rose S, et al. A patient safety curriculum for graduate medical education: results from a needs assessment of…
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psnet.ahrq.gov/issue/fostering-patient-safety-competencies-using-multiple-patient-simulation-experiences
January 12, 2022 - Study
Fostering patient safety competencies using multiple-patient simulation experiences.
Citation Text:
Ironside PM, Jeffries PR, Martin A. Fostering patient safety competencies using multiple-patient simulation experiences. Nurs Outlook. 2009;57(6):332-7. doi:10.1016/j.outlook.2009.0…
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psnet.ahrq.gov/issue/understanding-patient-safety-performance-and-educational-needs-using-safety-ii-approach
September 28, 2016 - Commentary
Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems.
Citation Text:
McNab D, Bowie P, Morrison J, et al. Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex syst…
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psnet.ahrq.gov/issue/examining-july-effect-national-survey-academic-leaders-medicine
July 05, 2016 - Study
Examining the July Effect: a national survey of academic leaders in medicine.
Citation Text:
Levy K, Voit J, Gupta A, et al. Examining the July Effect: A National Survey of Academic Leaders in Medicine. Am J Med. 2016;129(7):754.e1-5. doi:10.1016/j.amjmed.2016.05.001.
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psnet.ahrq.gov/issue/medicines-safety-anaesthetic-practice
February 02, 2022 - Review
Medicines safety in anaesthetic practice.
Citation Text:
Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Edu. 2019;19(5):151-157. doi:10.1016/j.bjae.2019.01.001.
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psnet.ahrq.gov/issue/corridor-care-emergency-department-managing-patient-care-non-clinical-areas-safely-and
May 19, 2021 - Commentary
'Corridor care' in the emergency department: managing patient care in non-clinical areas safely and efficiently.
Citation Text:
Williams C. ‘Corridor care’ in the emergency department: managing patient care in non-clinical areas safely and efficiently. Emerg Nurse. 2023;31(6):…
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psnet.ahrq.gov/issue/knowledge-translation-critical-care-factors-associated-prescription-commonly-recommended-best
October 31, 2011 - Study
Knowledge translation in critical care: factors associated with prescription of commonly recommended best practices for critically ill patients.
Citation Text:
Ilan R, Fowler RA, Geerts R, et al. Knowledge translation in critical care: factors associated with prescription of comm…
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psnet.ahrq.gov/issue/limited-health-literacy-barrier-medication-reconciliation-ambulatory-care
March 24, 2010 - Study
Limited health literacy is a barrier to medication reconciliation in ambulatory care.
Citation Text:
Persell SD, Osborn CY, Richard R, et al. Limited health literacy is a barrier to medication reconciliation in ambulatory care. J Gen Intern Med. 2007;22(11):1523-6.
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psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care
November 16, 2022 - Study
The Human Factors Analysis Classification System (HFACS) applied to health care.
Citation Text:
Diller T, Helmrich G, Dunning S, et al. The Human Factors Analysis Classification System (HFACS) applied to health care. Am J Med Qual. 2014;29(3):181-190. doi:10.1177/1062860613491623. …
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psnet.ahrq.gov/issue/its-difference-between-life-and-death-views-professional-medical-interpreters-their-role
August 10, 2010 - Study
"It's the difference between life and death": the views of professional medical interpreters on their role in the delivery of safe care to patients with limited English proficiency.
Citation Text:
Wu MS, Rawal S. "It's the difference between life and death": The views of profession…