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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
Citation Text:
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs015459-goldberg-final-report-2008.pdf
January 01, 2008 - Home Heart Failure (HF) Care Comparing Patient-Driven Technology Models
Grant Final Report
Grant ID: 5R01HS015459
Home Heart Failure (HF) Care Comparing
Patient-Driven Technology Models
Inclusive Dates: 09/30/04 - 09/09/08
Principal Investigator:
Lee R. Goldberg, MD, MPH
Team Members…
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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:
Google Scholar BibTe…
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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/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/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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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm5.html
October 01, 2014 - Designing and Implementing Medicaid Disease and Care Management Programs
Section 5: Selecting a Care Management Program Model
Previous Page Next Page
Table of Contents
Designing and Implementing Medicaid Disease and Care Management Programs
Introduction
Section 1: Planning a Care Management Prog…
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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/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:
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Harney_89.pdf
May 01, 2007 - Clinical Impact of an Anticoagulation Screening Service at a Pediatric Tertiary Care Facility
Clinical Impact of an Anticoagulation Screening
Service at a Pediatric Tertiary Care Facility
Kathy M. Harney, MS, RN, PNP; Patricia A. Branowicki, MS, RN, CNAA;
Margaret McCabe, DNSc, RN, APRN, BC; Kathleen Houlahan, M…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/rheumatoid-arthritis-medicine_executive.pdf
April 01, 2012 - 1
Comparative Effectiveness Review
Number 55
Drug Therapy for Rheumatoid Arthritis in
Adults: An Update
Executive Summary
Background
Rheumatoid arthritis (RA), which
affects 1.3 million adult Americans, is
an autoimmune disease that involves
inflammation of the synovium (a thin
layer of tissue lining a joint …
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psnet.ahrq.gov/node/34136/psn-pdf
January 29, 2018 - Institute for Healthcare Improvement.
January 29, 2018
53 State Street, 19th Floor, Boston, MA 02109. 617-301-4800, info@ihi.org.
https://psnet.ahrq.gov/issue/institute-healthcare-improvement
The Institute for Healthcare Improvement (IHI) is a not-for-profit organization promoting health improvement
by advancing t…
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digital.ahrq.gov/sites/default/files/docs/resource/Joanne_Pohl_IQHIT_Q1_Communications_Tracking_Tool.pdf
June 16, 2021 - Communications Tracking to Document Partnership Support
Communications Tracking to Document Partnership Support
1. Maintain log of phone and face to face communications:
Date
Communication
type (e.g.: Face
to face meeting,
conference call,
phone request)
Who present Initiated
by Length Key
agenda/…
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psnet.ahrq.gov/node/845346/psn-pdf
March 01, 2023 - The relationship between safety climate and safety
performance: a review.
March 1, 2023
Syed-Yahya SNN, Idris MA, Noblet AJ. The relationship between safety climate and safety performance: a
review. J Safety Res. 2022;83:105-118. doi:10.1016/j.jsr.2022.08.008.
https://psnet.ahrq.gov/issue/relationship-between-safe…
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psnet.ahrq.gov/node/35319/psn-pdf
September 14, 2005 - Perceived impact of duty hours limits on the
fragmentation of patient care: results from an academic
health center.
September 14, 2005
Keating RJ; LaRusso NF; Kolars JC.
https://psnet.ahrq.gov/issue/perceived-impact-duty-hours-limits-fragmentation-patient-care-results-
academic-health-center
The authors surveyed…
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psnet.ahrq.gov/node/36521/psn-pdf
January 07, 2011 - Safeguarding patients: complexity science, high reliability
organizations, and implications for team training in
healthcare.
January 7, 2011
McKeon LM, Oswaks JD, Cunningham PD. Safeguarding patients: complexity science, high reliability
organizations, and implications for team training in healthcare. Clin Nurse S…
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psnet.ahrq.gov/node/43202/psn-pdf
September 11, 2023 - ISMP Survey on High-Alert Medications in Acute Care
Settings.
September 11, 2023
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2023.
https://psnet.ahrq.gov/issue/ismp-survey-high-alert-medications-acute-care-settings
Experience from the sharp end helps to inform safety improvement initiatives. The…
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psnet.ahrq.gov/node/36425/psn-pdf
December 22, 2010 - Patient safety in the clinical laboratory: a longitudinal
analysis of specimen identification errors.
December 22, 2010
Wagar EA, Tamashiro L, Yasin B, et al. Patient safety in the clinical laboratory: a longitudinal analysis of
specimen identification errors. Arch Pathol Lab Med. 2006;130(11):1662-1668.
https://p…
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psnet.ahrq.gov/node/50680/psn-pdf
November 20, 2019 - The health care industry needs to be more honest about
medical errors.
November 20, 2019
Sutcliffe K. Time Magazine. November 5, 2019.
https://psnet.ahrq.gov/issue/health-care-industry-needs-be-more-honest-about-medical-errors
Experts agree that while some progress has been made since To Err is Human was published…