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psnet.ahrq.gov/node/49477/psn-pdf
April 01, 2005 - Hold the tPA
April 1, 2005
Fagan SC. Hold the tPA. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hold-tpa
The Case
A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency
department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…
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psnet.ahrq.gov/node/867980/psn-pdf
March 25, 2025 - Not All Headaches are Due to Migraine: Red Flags, Don’t
Miss Diagnoses, and Diagnostic Pitfalls
March 25, 2025
Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic
Pitfalls. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-fla…
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psnet.ahrq.gov/node/49488/psn-pdf
August 21, 2005 - PCA Overdose
August 21, 2005
Doyle JD. PCA Overdose. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pca-overdose
The Case
A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo-
oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…
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psnet.ahrq.gov/node/35155/psn-pdf
April 03, 2008 - Safer Healthcare Now!
April 3, 2008
Canadian Patient Safety Institute.
https://psnet.ahrq.gov/issue/safer-healthcare-now
Originally launched in 2005, this campaign seeks to implement evidence-based strategies to improve
patient safety in Canadian hospitals. In April 2008, the initiative added four new intervention…
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psnet.ahrq.gov/node/37660/psn-pdf
April 02, 2008 - An interdisciplinary approach to safer blood transfusion.
April 2, 2008
LaRocco M, Brient K. Patient Saf Qual Healthc. March April 2008.
https://psnet.ahrq.gov/issue/interdisciplinary-approach-safer-blood-transfusion
This article reports on one hospital's efforts to improve blood transfusion safety by implementing …
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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/node/841566/psn-pdf
December 14, 2022 - In Conversation With... Dr. Michelle Schreiber on
Measuring Patient Safety
December 14, 2022
In Conversation With.. Dr. Michelle Schreiber on Measuring Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
Editor’s Note: Michelle Schr…
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psnet.ahrq.gov/node/36481/psn-pdf
December 06, 2006 - Introduction to Trigger Tools for Identifying Adverse
Events.
December 6, 2006
Institute for Healthcare Improvement; IHI
https://psnet.ahrq.gov/issue/introduction-trigger-tools-identifying-adverse-events
This Web page provides summaries of and links to the various trigger tools available from the Institute for
He…
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psnet.ahrq.gov/node/35589/psn-pdf
June 17, 2010 - Health for life. Keys to safer hospitals.
June 17, 2010
Berwick DM. Health for life. 6 keys to safer hospitals. Newsweek. 2005;146(24):76-8.
https://psnet.ahrq.gov/issue/health-life-keys-safer-hospitals
Institute for Healthcare Improvement President Don Berwick summarizes the six improvement measures of
the 100K L…
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psnet.ahrq.gov/node/40864/psn-pdf
October 19, 2011 - Pressing for better quality across healthcare.
October 19, 2011
Levey NN.
https://psnet.ahrq.gov/issue/pressing-better-quality-across-healthcare
This newspaper article reports on improving US health care and profiles Dr. Donald Berwick, highlighting
his commitment and contributions to patient safety and quality wo…
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psnet.ahrq.gov/node/33758/psn-pdf
December 01, 2013 - In Conversation With… Hardeep Singh, MD, MPH
December 1, 2013
In Conversation With… Hardeep Singh, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
Editor's note: Hardeep Singh, MD, MPH, is Chief of the Health Policy, Quality and Informatics Program at
the Hous…
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psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
October 30, 2024 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration
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June 14, 2023
Innov…
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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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psnet.ahrq.gov/node/49630/psn-pdf
July 01, 2011 - Watch the Warfarin!
July 1, 2011
Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/watch-warfarin
Case Objectives
Understand best practices for safe discharge of patients on warfarin.
Describe recent advances in anticoagulation monitoring for ambulatory patients.
Discu…
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psnet.ahrq.gov/node/49687/psn-pdf
August 21, 2013 - Emergency Error
August 21, 2013
Symons NRA. Emergency Error. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/emergency-error
Case Objectives
State that emergency surgery is high risk and has high mortality.
Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of
…
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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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…
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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/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…