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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
November 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case November 2005
Reconciling Doses
Source and Credits
This presentation is based on the November 2005 Spotlight Case in Emergency Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Frank Federico, RPh,…
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psnet.ahrq.gov/node/60193/psn-pdf
July 01, 2022 - Improving Diagnosis and Treatment of Maternal Sepsis.
April 1, 2020
Stanford, CA; California Maternal Quality Care Collaborative: July 1, 2022.
https://psnet.ahrq.gov/issue/improving-diagnosis-and-treatment-maternal-sepsis
This toolkit focuses on identification of, and rapid response to, sepsis in obstetric p…
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psnet.ahrq.gov/node/847542/psn-pdf
April 12, 2023 - Imagining the future of diagnostic performance feedback.
April 12, 2023
Rosner BI, Zwaan L, Olson APJ. Imagining the future of diagnostic performance feedback. Diagnosis
(Berl). 2023;10(1):31-37. doi:10.1515/dx-2022-0055.
https://psnet.ahrq.gov/issue/imagining-future-diagnostic-performance-feedback
Peer feedback i…
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psnet.ahrq.gov/node/45580/psn-pdf
July 24, 2019 - Overview of Patient Safety Learning Laboratory Projects.
July 24, 2019
Rockville, MD: Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/overview-patient-safety-learning-laboratory-projects
Collaborative strategies can enable individuals and organizations to learn from each other to support
p…
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psnet.ahrq.gov/node/846765/psn-pdf
March 29, 2023 - Addressing Medical Gaslighting to Improve Maternal
Health—Together.
March 29, 2023
Oregon Patient Safety Commission: 2023.
https://psnet.ahrq.gov/issue/addressing-medical-gaslighting-improve-maternal-health-together
Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit …
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psnet.ahrq.gov/node/36446/psn-pdf
March 28, 2011 - Healthcare provider complaints to the emergency
department: a preliminary report on a new quality
improvement instrument.
March 28, 2011
Griffey RT, Bohan JS. Healthcare provider complaints to the emergency department: a preliminary report
on a new quality improvement instrument. Qual Saf Health Care. 2006;15(5):3…
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psnet.ahrq.gov/node/47475/psn-pdf
January 23, 2019 - Patient Safety and Quality Improvement.
January 23, 2019
Shah RK, ed. Otolaryngol Clin North Am. 2019;52:1-194.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-0
Articles in this special issue apply safety concepts to reducing preventable patient harm in otolaryngology.
The reviews highlight sy…
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psnet.ahrq.gov/node/860400/psn-pdf
January 10, 2024 - AHA Patient Safety Initiative.
January 10, 2024
American Hospital Association.
https://psnet.ahrq.gov/issue/aha-patient-safety-initiative
Leadership at the organization and system level is crucial to gaining improvement traction and
sustainability. This initiative centers on safety culture, care inequities, and wo…
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psnet.ahrq.gov/node/38701/psn-pdf
June 28, 2011 - Selection of indicators for continuous monitoring of
patient safety: recommendations of the project 'safety
improvement for patients in Europe.'
June 28, 2011
Kristensen S, Mainz J, Bartels P. Selection of indicators for continuous monitoring of patient safety:
recommendations of the project 'safety improvement f…
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psnet.ahrq.gov/node/61104/psn-pdf
March 03, 2025 - NAM Scholars in Diagnostic Excellence program.
January 10, 2025
National Academy of Medicine and the Council of Medical Specialty Societies.
https://psnet.ahrq.gov/issue/nam-scholars-diagnostic-excellence-program
Diagnostic error reduction is gaining momentum as a primary focus of patient safety achievement. This
…
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psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
March 30, 2020 - In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD
March 30, 2020
Also Read the Essay
Citation Text:
In Conversation With.. Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD. PSNet [internet]. 2020.In Conversation With... Ann Gaffey, RN, MS…
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - SPOTLIGHT CASE
Spotlight: Mistaken Attribution, Diagnostic Misstep
Citation Text:
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citat…
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psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx
Spotlight
Failure to Ensure Patient Safety Leads to Patient Falls in
Nursing Homes
Source and Credits
• This presentation is based on the April 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/we…
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psnet.ahrq.gov/issue/application-global-trigger-tool-systematic-review
December 06, 2023 - Review
The application of the Global Trigger Tool: a systematic review.
Citation Text:
Hibbert PD, Molloy CJ, Hooper TD, et al. The application of the Global Trigger Tool: a systematic review. Int J Qual Health Care. 2016;28(6):640-649. doi:10.1093/intqhc/mzw115.
Copy Citation
For…
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psnet.ahrq.gov/issue/natural-language-processing-and-its-implications-future-medication-safety-narrative-review
December 21, 2014 - Review
Emerging Classic
Natural language processing and its implications for the future of medication safety: a narrative review of recent advances and challenges.
Citation Text:
Wong A, Plasek JM, Montecalvo SP, et al. Natural Language Processing and Its Implic…
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psnet.ahrq.gov/issue/measurement-patient-safety-systematic-review-reliability-and-validity-adverse-event-detection
November 16, 2016 - Review
Measurement of patient safety: a systematic review of the reliability and validity of adverse event detection with record review.
Citation Text:
Hanskamp-Sebregts M, Zegers M, Vincent CA, et al. Measurement of patient safety: a systematic review of the reliability and validity of …
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psnet.ahrq.gov/issue/business-case-quality-economic-analysis-michigan-keystone-patient-safety-program-icus
September 20, 2011 - Study
Classic
The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs.
Citation Text:
Waters HR, Korn R, Colantuoni E, et al. The business case for quality: economic analysis of the Michigan Keystone Patient Saf…
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psnet.ahrq.gov/issue/motivation-patient-engagement-patient-safety-multi-perspective-explorative-survey
June 17, 2020 - Study
Motivation for patient engagement in patient safety: a multi-perspective, explorative survey.
Citation Text:
Raab C, Gambashidze N, Brust L, et al. Motivation for patient engagement in patient safety: a multi-perspective, explorative survey. BMC Health Serv Res. 2024;24(1):1052. do…
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psnet.ahrq.gov/issue/pending-studies-hospital-discharge-pre-post-analysis-electronic-medical-record-tool-improve
September 16, 2020 - Study
Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge.
Citation Text:
Kantor MA, Evans KH, Shieh L. Pending studies at hospital discharge: a pre-post analysis of an electronic medical record to…
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psnet.ahrq.gov/issue/american-college-surgeons-committee-trauma-performance-improvement-and-patient-safety-program
September 23, 2020 - Study
American College of Surgeons' Committee on Trauma performance improvement and patient safety program: maximal impact in a mature trauma center.
Citation Text:
Sarkar B, Brunsvold ME, Cherry-Bukoweic JR, et al. American College of Surgeons' Committee on Trauma Performance Improvem…