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psnet.ahrq.gov/web-mm/workaround-error
October 30, 2024 - Workaround Error
Citation Text:
Pape T. Workaround Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable
Citation Text:
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/node/49532/psn-pdf
March 15, 2007 - Back to Basics
March 1, 2007
Hellman R. Back to Basics. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/back-basics
The Case
A 48-year-old woman with insulin-dependent diabetes mellitus presents to the emergency department with
right upper quadrant pain, fever, and leukocytosis, prompting admission for pres…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
May 01, 2018 - Spotlight
Spotlight
Out of Sight, Out of Mind: Out-of-Office Test Result Management
1
Source and Credits
This presentation is based on the May 2018
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Eric Poon, MD, MPH, Duke University School o…
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psnet.ahrq.gov/node/33876/psn-pdf
August 01, 2018 - Building a Safety Program in a Vast Health Care Network
March 1, 2019
Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
Perspective
Background
As hospital-based health care in the United …
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psnet.ahrq.gov/node/33698/psn-pdf
August 01, 2010 - In Conversation with...Richard P. Shannon, MD
August 1, 2010
In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
Editor's note: Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the
University of Pe…
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - Medication Errors and Adverse Drug Events
Citation Text:
Medication Errors and Adverse Drug Events. 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/node/73303/psn-pdf
May 26, 2021 - Safety Culture in EMS
May 26, 2021
Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/safety-culture-ems
Defining a Just Culture
A Just Culture is one that supports transparent and honest error reporting with the goal of fostering an
environmen…
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psnet.ahrq.gov/node/33872/psn-pdf
January 01, 2018 - Update: Patient Engagement in Safety
January 1, 2018
Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/update-patient-engagement-safety
Annual Perspective 2018
Background
Patient engagement has become a cornerstone of patient safety. A Patient Saf…
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psnet.ahrq.gov/primer/reporting-patient-safety-events
March 30, 2022 - Reporting Patient Safety Events
Citation Text:
Reporting Patient Safety Events. 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/node/44568/psn-pdf
October 21, 2015 - Developing and deploying a patient safety program in a
large health care delivery system: you can't fix what you
don't know about.
October 21, 2015
Bagian JP, Lee C, Gosbee J, et al. Developing and deploying a patient safety program in a large health
care delivery system: you can't fix what you don't know about. J…
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psnet.ahrq.gov/node/73622/psn-pdf
August 25, 2021 - The presence and potential impact of psychological
safety in the healthcare setting: an evidence synthesis.
August 25, 2021
Grailey KE, Murray E, Reader T, et al. The presence and potential impact of psychological safety in the
healthcare setting: an evidence synthesis. BMC Health Serv Res. 2021;21(1):773. doi:10.1…
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psnet.ahrq.gov/node/61068/psn-pdf
October 28, 2020 - Are dental patients concerned about safety? An
exploratory study.
October 28, 2020
Obadan-Udoh E, Panwar S, Yansane A-I, et al. Are dental patients concerned about safety? An exploratory
study. J Evid Based Dent Pract. 2020;20(3):101424. doi:10.1016/j.jebdp.2020.101424.
https://psnet.ahrq.gov/issue/are-dental-pati…
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psnet.ahrq.gov/node/73986/psn-pdf
October 20, 2021 - Fidelity and the impact of patient safety huddles on
teamwork and safety culture: an evaluation of the Huddle
Up for Safer Healthcare (HUSH) project.
October 20, 2021
Lamming L, Montague J, Crosswaite K, et al. Fidelity and the impact of patient safety huddles on teamwork
and safety culture: an evaluation of the H…
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psnet.ahrq.gov/node/72650/psn-pdf
January 20, 2021 - A roadmap to advance patient safety in ambulatory care.
January 20, 2021
Singh H, Carayon P. A roadmap to advance patient safety in ambulatory care. JAMA. 2020;324(24):2481-
2482. doi:10.1001/jama.2020.18551.
https://psnet.ahrq.gov/issue/roadmap-advance-patient-safety-ambulatory-care
Preventable harm, such as diag…
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psnet.ahrq.gov/node/72814/psn-pdf
March 10, 2021 - Implementing a human factors approach to RCA(2) :
tools, processes and strategies.
March 10, 2021
Wiegmann DA, Wood LJ, Solomon DB, et al. Implementing a human factors approach to RCA(2) : tools,
processes and strategies. J Healthc Risk Manag. 2021;41(1):31-46. doi:10.1002/jhrm.21454.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/846448/psn-pdf
March 22, 2023 - Understanding patient and clinician reported nonroutine
events in ambulatory surgery.
March 22, 2023
Salwei ME, Anders S, Slagle JM, et al. Understanding patient and clinician reported nonroutine events in
ambulatory surgery. J Patient Saf. 2023;19(2):e38-e45. doi:10.1097/pts.0000000000001089.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/854635/psn-pdf
January 01, 2024 - CheckPOINT: a simple tool to measure Surgical Safety
Checklist implementation fidelity.
October 18, 2023
Moyal-Smith R, Etheridge JC, Turley N, et al. CheckPOINT: a simple tool to measure Surgical Safety
Checklist implementation fidelity. BMJ Qual Saf. 2024;33(4):223-231. doi:10.1136/bmjqs-2023-016030.
https://psn…
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psnet.ahrq.gov/node/46116/psn-pdf
May 24, 2017 - Elimination of emergency department medication errors
due to estimated weights.
May 24, 2017
Greenwalt M, Griffen D, Wilkerson J. Elimination of Emergency Department Medication Errors Due To
Estimated Weights. BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u214416.w5476.
https://psnet.ahrq.gov/issue/elimin…
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psnet.ahrq.gov/node/47239/psn-pdf
October 24, 2018 - Effects of individual nurse and hospital characteristics on
patient adverse events and quality of care: a multilevel
analysis.
October 24, 2018
Lee SE, Vincent C, Dahinten S, et al. Effects of Individual Nurse and Hospital Characteristics on Patient
Adverse Events and Quality of Care: A Multilevel Analysis. J Nurs…