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psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
April 01, 2018 - with postdischarge instructions.( 19 )
As we consider the Post-Hospital Syndrome, we should also incorporate
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psnet.ahrq.gov/classics
August 01, 2023 - This position paper defines adaptive CDS as “systems that can learn and change performance over time, incorporate
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psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - with postdischarge instructions.( 19 )
As we consider the Post-Hospital Syndrome, we should also incorporate
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psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
March 01, 2019 - Building a Safety Program in a Vast Health Care Network
Paul E. Phrampus, MD | March 1, 2019
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Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet].…
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psnet.ahrq.gov/node/867676/psn-pdf
February 26, 2025 - Responding to Patient Safety Events
February 26, 2025
Shaikh U. Responding to Patient Safety Events. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/responding-patient-safety-events
Background
Patient safety events that occur in health care facilities require prompt action to ensure that further harm is
mit…
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psnet.ahrq.gov/node/33571/psn-pdf
March 15, 2025 - Reporting Patient Safety Events
March 15, 2025
Reporting Patient Safety Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/reporting-patient-safety-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in th…
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psnet.ahrq.gov/primer/medication-reconciliation
March 15, 2025 - Medication Reconciliation
Citation Text:
Medication Reconciliation. 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/846170/psn-pdf
March 15, 2023 - Interventions
Pharmacy-led medication reconciliation
There are several changes that organizations can incorporate
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psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
November 16, 2022 - those obtained by peripheral venipuncture.( 12-14 ) Fourth, modern blood culture systems and media that incorporate
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - These decision support tools should incorporate the absolute need to give insulin to patients with type
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
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May 29, 2024
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August 01, 2005 - Payment reforms must incorporate the reality that decreasing hospital length of stay and technology advancements
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - Caregivers should incorporate reporting into routine practice.
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psnet.ahrq.gov/print/pdf/node/866100
August 30, 2023 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Nurse Wellbeing and Patient Safety
Curated Library
Foundations
Keeping Patients Safe: Transforming the Work Environment of Nurses.
Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care
Services. Wash…
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psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
December 02, 2020 - SPOTLIGHT CASE
The Lost Start Date: an Unknown Risk of E-prescribing
Citation Text:
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. 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/print/pdf/node/73848
July 01, 2022 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Maternal Safety
Curated Library
Foundations
Maternal Safety
Marla Shauer, PhD(c), MSN, CNM; Amy Nichols, EdD, RN, CNS, CHSE, ANEF; Audrey Lyndon, RN,
PhD, FAAN | January, 31 2024
Pregnancy, childbirth, and the postpartum year present a comp…
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psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
March 24, 2019 - Hypoxemia after Emergency Intubation
Citation Text:
Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - negative emotional reactions to strangers and pain. 6 Levels of sedation Nearly all sedation scales incorporate
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - Interventions
Pharmacy-led medication reconciliation
There are several changes that organizations can incorporate
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psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
April 26, 2023 - this field with their CDS Innovation Collaborative project. 20 Finally, as it becomes more common to incorporate