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psnet.ahrq.gov/node/49402/psn-pdf
June 01, 2003 - Inappropriate Antibiotic Use
June 1, 2003
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
The Case
A 41-year-old woman presented to the hospital with acute renal failure, which came to be diagnosed as a
first presentation of s…
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - SPOTLIGHT CASE
All in the History
Citation Text:
Fee C. All in the History. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
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psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
December 02, 2020 - Updates in the Management of High-Risk Pulmonary Embolism
Citation Text:
Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Forma…
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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - SPOTLIGHT CASE
Cognitive Overload in the ICU
Citation Text:
Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
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psnet.ahrq.gov/sites/default/files/2022-05/final_cme_reviewed_-_spotlight_missing_a_large_vessel_occlusion_stroke_04.14.2022_-_copy.pdf
January 01, 2022 - Spotlight
Spotlight
Missing a Large Vessel Occlusion Stroke in
a Patient with a History of Seizures
Source and Credits
• This presentation is based on the May 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Kevin Keenan, MD and D…
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psnet.ahrq.gov/node/837215/psn-pdf
July 08, 2022 - Missing a Large Vessel Occlusion Stroke in a Patient with
a History of Seizures.
July 8, 2022
Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizure…
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psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - Hidden Heparins: HIT Happens
December 1, 2006
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
Case Objectives
Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication,
thrombosis.
Discuss the managem…
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near-
Miss Wrong Transfusion Event
January 29, 2020
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
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psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workforce-challenges
August 30, 2023 - For example, a telehealth initiative was established to improve access to telehealth for high-risk … Sue Schuelke: We embrace CHI’s SafetyFirst Initiative .
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psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schuelke-about-virtual-nursing
August 30, 2023 - Sue Schuelke: We embrace CHI’s SafetyFirst Initiative . … For example, a telehealth initiative was established to improve access to telehealth for high-risk
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psnet.ahrq.gov/node/851568/psn-pdf
July 31, 2023 - psnet.ahrq.gov/issue/infusion-medication-error-reduction-two-person-verification-quality-improvement-initiative … Infusion medication error reduction by two-person
verification: a quality improvement initiative.
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psnet.ahrq.gov/node/60755/psn-pdf
August 05, 2020 - Patient safety from executive hospital management to
wards: a qualitative study identifying factors influencing
implementation.
August 5, 2020
Conner T, Unsworth J, Machin A. Patient safety from executive hospital management to wards: a
qualitative study identifying factors influencing implementation. J Nurs Manag…
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psnet.ahrq.gov/node/867527/psn-pdf
January 15, 2025 - Interventions to improve timely cancer diagnosis: an
integrative review.
January 15, 2025
Graber ML, Winters BD, Matin R, et al. Interventions to improve timely cancer diagnosis: an integrative
review. Diagnosis (Berl). 2024;Epub Oct 18. doi:10.1515/dx-2024-0113.
https://psnet.ahrq.gov/issue/interventions-improve-…
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psnet.ahrq.gov/node/847056/psn-pdf
April 05, 2023 - Early diagnosis of cancer: systems approach to support
clinicians in primary care.
April 5, 2023
Black GB, Lyratzopoulos G, Vincent CA, et al. Early diagnosis of cancer: systems approach to support
clinicians in primary care. BMJ. 2023;380:e071225. doi:10.1136/bmj-2022-071225.
https://psnet.ahrq.gov/issue/early-di…
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psnet.ahrq.gov/node/41701/psn-pdf
September 26, 2019 - The CUSP Method
September 26, 2019
The CUSP Method.
https://psnet.ahrq.gov/issue/cusp-method
The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital
by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in
several landmark pat…
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psnet.ahrq.gov/node/34995/psn-pdf
February 03, 2011 - The Research on Adverse Drug Events and Reports
(RADAR) project.
February 3, 2011
Bennett CL, Nebeker JR, Lyons A, et al. The Research on Adverse Drug Events and Reports (RADAR)
project. JAMA. 2005;293(17):2131-40.
https://psnet.ahrq.gov/issue/research-adverse-drug-events-and-reports-radar-project
This article su…
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psnet.ahrq.gov/node/46276/psn-pdf
August 02, 2017 - Vital signs: changes in opioid prescribing in the United
States, 2006-2015.
August 2, 2017
Guy GP, Zhang K, Bohm MK, et al. Vital Signs: Changes in Opioid Prescribing in the United States, 2006-
2015. MMWR Morb Mortal Wkly Rep. 2017;66(26):697-704. doi:10.15585/mmwr.mm6626a4.
https://psnet.ahrq.gov/issue/vital-sig…
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psnet.ahrq.gov/node/74729/psn-pdf
February 02, 2022 - Healing our own: a randomized trial to assess benefits of
peer support.
February 2, 2022
Rivera-Chiauzzi EY, Smith HA, Moore-Murray T, et al. Healing our own: a randomized trial to assess
benefits of peer support. J Patient Saf. 2022;18(1):e308-e314. doi:10.1097/pts.0000000000000771.
https://psnet.ahrq.gov/issue/h…
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psnet.ahrq.gov/node/45009/psn-pdf
March 30, 2016 - Fatal mistakes.
March 30, 2016
Kliff S. Vox Media. March 15, 2016.
https://psnet.ahrq.gov/issue/fatal-mistakes
Health professionals involved in medical errors experience psychological stress, which can have serious
consequences if they are unable to cope with their mistake. Reporting on the second victim phenomeno…
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psnet.ahrq.gov/node/46147/psn-pdf
August 08, 2018 - A Department of Medicine infrastructure for patient safety
and clinical quality improvement.
August 8, 2018
Mathews SC, Pronovost P, Biddison LD, et al. A Department of Medicine Infrastructure for Patient Safety
and Clinical Quality Improvement. Am J Med Qual. 2018;33(4):413-419. doi:10.1177/1062860617743324.
http…