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psnet.ahrq.gov/issue/improving-safety-during-transitions-care-through-use-electronic-referral-loops-receive-and
October 19, 2022 - Study
Improving safety during transitions of care through the use of electronic referral loops to receive and reconcile health information.
Citation Text:
Allen G, Setzer J, Jones R, et al. Improving safety during transitions of care through the use of electronic referral loops to receiv…
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psnet.ahrq.gov/issue/nurses-perspectives-medication-errors-and-prevention-strategies-residential-aged-care
July 13, 2010 - Study
Nurses' perspectives on medication errors and prevention strategies in residential aged care facilities through a national survey.
Citation Text:
Kuppadakkath SC, Bhowmik J, Olasoji M, et al. Nurses' perspectives on medication errors and prevention strategies in residential aged ca…
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psnet.ahrq.gov/issue/role-pediatric-nurses-during-preventable-adverse-event-disclosure-scoping-review
October 19, 2022 - Review
The role of pediatric nurses during preventable adverse event disclosure: a scoping review.
Citation Text:
Sexton JR, Kelly-Weeder S. The role of pediatric nurses during preventable adverse event disclosure: a scoping review. J Patient Saf. 2024;20(6):381-387. doi:10.1097/pts.0000…
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psnet.ahrq.gov/issue/we-thought-we-would-be-perfect-medication-errors-and-after-initiation-computerized-physician
September 18, 2019 - Study
We thought we would be perfect: medication errors before and after the initiation of computerized physician order entry.
Citation Text:
Schwartzberg D, Ivanovic S, Patel S, et al. We thought we would be perfect: medication errors before and after the initiation of Computerized Phys…
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psnet.ahrq.gov/issue/defining-minimum-necessary-anticoagulation-related-communication-discharge-consensus-care
March 04, 2020 - Study
Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.
Citation Text:
Triller D, Myrka A, Gassler J, et al. Defining Minimum Necessary Anticoagulation-Related Commu…
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psnet.ahrq.gov/issue/initial-assessment-patient-handoff-accredited-general-surgery-residency-programs-united
October 19, 2022 - Study
Initial assessment of patient handoff in accredited general surgery residency programs in the United States and Canada: a cross-sectional survey.
Citation Text:
Saleem AM, Paulus JK, Vassiliou MC, et al. Initial assessment of patient handoff in accredited general surgery residency …
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psnet.ahrq.gov/issue/quality-initiative-decrease-pathology-specimen-labeling-errors-using-radiofrequency
August 28, 2017 - Study
A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center.
Citation Text:
Francis DL, Prabhakar S, Sanderson SO. A quality initiative to decrease pathology specimen-labeling errors using radiofrequenc…
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psnet.ahrq.gov/issue/quality-improvement-initiative-using-peer-audit-and-feedback-improve-compliance-surgical
March 24, 2021 - Study
A quality improvement initiative using peer audit and feedback to improve compliance with the surgical safety checklist.
Citation Text:
Fridrich A, Imhof A, Staender S, et al. A quality improvement initiative using peer audit and feedback to improve compliance. Int J Qual Health C…
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psnet.ahrq.gov/node/851053/psn-pdf
June 28, 2023 - In situ simulation as a quality improvement tool to identify
and mitigate latent safety threats for emergency
department SARS-CoV-2 airway management: a multi-
institutional initiative.
June 28, 2023
Yang CJ, Saggar V, Seneviratne N, et al. In situ simulation as a quality improvement tool to identify and
mitigate…
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psnet.ahrq.gov/node/41702/psn-pdf
November 07, 2018 - AHRQ patient safety project reduces bloodstream
infections by 40 percent.
November 7, 2018
Schmidt B. Patient Saf Qual Hcare. September 12, 2012.
https://psnet.ahrq.gov/issue/ahrq-patient-safety-project-reduces-bloodstream-infections-40-percent
The near elimination of central line–associated bloodstream infections…
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psnet.ahrq.gov/node/844996/psn-pdf
February 22, 2023 - In situ simulation as a tool to longitudinally identify and
track latent safety threats in a structured quality
improvement initiative for SARS-CoV-2 airway
management: a single-center study.
February 22, 2023
Jafri FN, Yang CJ, Kumar A, et al. In situ simulation as a tool to longitudinally identify and track late…
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psnet.ahrq.gov/node/36105/psn-pdf
May 27, 2011 - Computerized provider order entry implementation: no
association with increased mortality rates in an intensive
care unit.
May 27, 2011
Del Beccaro MA, Jeffries HE, Eisenberg MA, et al. Computerized provider order entry implementation: no
association with increased mortality rates in an intensive care unit. Pediat…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.149_slideshow.ppt
May 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case May 2007
Antiseizure Medication Disorder
Source and Credits
This presentation is based on the May 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Brian K. Alldredge, Pharm…
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psnet.ahrq.gov/node/49587/psn-pdf
May 01, 2009 - Missing Trauma
May 1, 2009
Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/missing-trauma
The Case
A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a
few minutes later by a customer, who immediately called 911. On arrival, para…
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - SPOTLIGHT CASE
Transfusion Thresholds in Gastrointestinal Bleeding
Citation Text:
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citati…
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psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure
to Rescue after Limited Response to Nursing Concerns.
July 10, 2024
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response
to Nursing Concerns. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hemorrhagic-sh…
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psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
October 26, 2022 - Diagnosing a Missed Diagnosis
Citation Text:
Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7…
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psnet.ahrq.gov/node/860050/psn-pdf
January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic
Infant.
January 4, 2024
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
The Case
A 2-month-old full-term male infant was b…
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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a
Patient Admitted for Leg Fractures
March 27, 2024
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
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psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx
Spotlight
Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full …