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psnet.ahrq.gov/issue/vital-signs-epidemiology-sepsis-prevalence-health-care-factors-and-opportunities-prevention
September 23, 2020 - Study
Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention.
Citation Text:
Novosad SA, Sapiano MRP, Grigg C, et al. Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care Factors and Opportunities for Prevention. MMWR Morb Mortal…
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psnet.ahrq.gov/issue/i-pass-illness-diversity-identifies-patients-risk-overnight-clinical-deterioration
November 16, 2022 - Study
I-PASS illness diversity identifies patients at risk for overnight clinical deterioration.
Citation Text:
Shah C, Sanber K, Jacobson R, et al. I-PASS illness diversity identifies patients at risk for overnight clinical deterioration. J Grad Med Educ. 2020;12(5):578-582. doi:10.4300…
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psnet.ahrq.gov/node/43268/psn-pdf
June 11, 2014 - Medication Safety Program.
June 11, 2014
Atlanta, GA: Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/medication-safety-program
This Web site provides information for providers and patients to reduce risks related to adverse drug
events, including links to fact sheets, research, and govern…
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psnet.ahrq.gov/node/36780/psn-pdf
April 29, 2018 - If safety is your yardstick, measuring culture from the top
down must be a priority.
April 29, 2018
ISMP Medication Safety Alert! Acute care edition. March 22, 2007.
https://psnet.ahrq.gov/issue/if-safety-your-yardstick-measuring-culture-top-down-must-be-priority
This article discusses the importance of a safety c…
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psnet.ahrq.gov/node/39980/psn-pdf
January 13, 2014 - Common formats for patient safety data collection and
event reporting.
January 13, 2014
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection-and-event-reporting-0
Use of common formats allows for comparison between facilities. This website provides …
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psnet.ahrq.gov/node/35432/psn-pdf
September 11, 2009 - Improving patient safety: moving beyond the "hype" of
medical errors.
September 11, 2009
Forster AJ, Shojania KG, van Walraven C. Improving patient safety: moving beyond the "hype" of medical
errors. CMAJ. 2005;173(8):893-4.
https://psnet.ahrq.gov/issue/improving-patient-safety-moving-beyond-hype-medical-errors
T…
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psnet.ahrq.gov/node/40001/psn-pdf
November 17, 2010 - Contributions from Ergonomics and Human Factors.
November 17, 2010
Qual Saf Health Care. 2010;19(suppl 3):i1-i79.
https://psnet.ahrq.gov/issue/contributions-ergonomics-and-human-factors
This special issue contains articles discussing human factors and ergonomics in health care simulation,
information techno…
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psnet.ahrq.gov/node/37591/psn-pdf
November 10, 2011 - Commentary on Sentinel & Serious Events Reported by
District Health Boards - 2006/07.
November 10, 2011
National Health Epidemiology and Quality Assurance Advisory Committee. Wellington, New Zealand;
Quality Improvement Committee; 2008.
https://psnet.ahrq.gov/issue/commentary-sentinel-serious-events-reported-distr…
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psnet.ahrq.gov/node/41308/psn-pdf
April 18, 2012 - Health Care–Associated Infections (HAI) Portal.
April 18, 2012
Joint Commission.
https://psnet.ahrq.gov/issue/health-care-associated-infections-hai-portal
This Web site provides resources on infection prevention and control, including standards, strategies,
educational tools, and setting-based information.
https:…
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psnet.ahrq.gov/node/33998/psn-pdf
March 17, 2011 - Minnesota Alliance for Patient Safety (MAPS).
March 17, 2011
Minnesota Hospital and Healthcare Partnership.
https://psnet.ahrq.gov/issue/minnesota-alliance-patient-safety-maps
The Minnesota Alliance for Patient Safety (MAPS) is a partnership among the Minnesota Hospital
Association, Minnesota Medical Associa…
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psnet.ahrq.gov/node/38990/psn-pdf
September 30, 2009 - Practice, rehearsal, and performance: an approach for
simulation-based surgical and procedure training.
September 30, 2009
Kneebone RL.
https://psnet.ahrq.gov/issue/practice-rehearsal-and-performance-approach-simulation-based-surgical-and-
procedure-training
Understanding how musical expertise is developed could …
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psnet.ahrq.gov/node/42499/psn-pdf
August 14, 2013 - A considerative checklist to ensure safe daily patient
review.
August 14, 2013
Mohan N, Caldwell G. A Considerative Checklist to ensure safe daily patient review. Clin Teach.
2013;10(4):209-13. doi:10.1111/tct.12023.
https://psnet.ahrq.gov/issue/considerative-checklist-ensure-safe-daily-patient-review
This commen…
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psnet.ahrq.gov/node/37239/psn-pdf
September 27, 2016 - Communication patterns in a UK emergency department.
September 27, 2016
Woloshynowych M, Davis R, Brown R, et al. Communication patterns in a UK emergency department. Ann
Emerg Med. 2007;50(4):407-13.
https://psnet.ahrq.gov/issue/communication-patterns-uk-emergency-department
This study observed emergency room cha…
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psnet.ahrq.gov/node/36996/psn-pdf
September 24, 2016 - Interruptions in a level one trauma center: a case study.
September 24, 2016
Brixey J, Tang Z, Robinson DJ, et al. Interruptions in a level one trauma center: a case study. Int J Med
Inform. 2008;77(4):235-41.
https://psnet.ahrq.gov/issue/interruptions-level-one-trauma-center-case-study
The investigators shadowed …
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psnet.ahrq.gov/node/35728/psn-pdf
February 22, 2006 - Safety climate in health care organizations: a
multidimensional approach.
February 22, 2006
Katz-Navon T; Naveh E; Stern Z. Academy of Management Journal. 2005;48(6):1075-1089.
https://psnet.ahrq.gov/issue/safety-climate-health-care-organizations-multidimensional-approach
The authors explored four elements of safe…
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psnet.ahrq.gov/node/36827/psn-pdf
April 25, 2007 - Adverse Drug Events in US Hospitals, 2004.
April 25, 2007
Elixhauser A, Owens P. HCUP Statistical Brief #29. Rockville, MD: Agency for Healthcare Research and
Quality; April 2007.
https://psnet.ahrq.gov/issue/adverse-drug-events-us-hospitals-2004
This report presents data on adverse drug events from the Healthcare…
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psnet.ahrq.gov/node/41865/psn-pdf
November 21, 2012 - 'Inattentional blindness': what captures your attention?
November 21, 2012
Grissinger M. 'Inattentional blindness': what captures your attention? P.T. 2012;37(10):542-555.
https://psnet.ahrq.gov/issue/inattentional-blindness-what-captures-your-attention-0
This commentary discusses inattentional blindness, how the b…
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psnet.ahrq.gov/node/37353/psn-pdf
March 28, 2012 - Medication Use: A Systems Approach to Reducing Errors,
Second Edition.
March 28, 2012
Porche? RA. Oakbrook Terrace, IL: Joint Commission Resources: 2008. ISBN 9781599400976.
https://psnet.ahrq.gov/issue/medication-use-systems-approach-reducing-errors-second-edition
Co-authored by a host of medication safety expert…
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psnet.ahrq.gov/node/37573/psn-pdf
December 23, 2016 - Preventing accidents and injuries in the MRI suite.
December 23, 2016
Preventing accidents and injuries in the MRI suite. Sentinel Event Alert. 2008;38(38):1-3.
https://psnet.ahrq.gov/issue/preventing-accidents-and-injuries-mri-suite
This alert provides risk reduction strategies and recommendations to minimize oppo…
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psnet.ahrq.gov/node/38003/psn-pdf
September 19, 2016 - Suicide in the medical setting.
September 19, 2016
Ballard ED, Pao M, Henderson D, et al. Suicide in the medical setting. Jt Comm J Qual Patient Saf.
2008;34(8):474-481.
https://psnet.ahrq.gov/issue/suicide-medical-setting
This review sought to differentiate suicides in hospitalized medical patients from suicides …