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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - In this institution, standard practice was that ambulatory surgery patients walked to the operating suite
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psnet.ahrq.gov/node/33656/psn-pdf
September 01, 2007 - As a teaching institution, we have to end up teaching surgeons and doctors, and we have to be
able to
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - encouraging patients to "speak up" when they see
something wrong.(2,3) Finally, as a faculty member at the institution
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psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - an indicator like death in a low-mortality DRG as a screening test, that, when positive, leads an institution
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - respiratory depression or needs a deeper level of sedation, such as moderate, deep, or general anesthesia, institution-specific
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - A Loss of Trust and a Missed Diagnosis
February 23, 2022
An institution-wide
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psnet.ahrq.gov/web-mm/check-twice-transport-once
March 15, 2023 - of transport (i.e., scheduled, urgent, or emergent) or level of automation available in a healthcare institution
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psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - Patient safety is an important issue at every health care institution in our country.
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psnet.ahrq.gov/node/60745/psn-pdf
October 01, 2020 - In this particular case, propofol was deemed as
an institution-specific controlled substance.
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psnet.ahrq.gov/web-mm/complaints-safety-surveillance
May 05, 2021 - timely, effective, and ethical way.( 6 ) Problematic practitioners are often "moved on" to another institution
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - abscess and performing root cause analysis using a DEER Taxonomy framework.( 13 ) This activity at our institution
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - Yet, if that is all that happened, the next child in this same condition in this same institution will
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Moreover, debriefs should focus on how cultural norms of the institution might contribute to errors.
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psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
August 15, 2017 - were process factors or deviations from the standard of care set by the policies and protocols of the institution
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Browse Author Resources
Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …
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psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - SPOTLIGHT CASE
Reconciling Doses
Citation Text:
Federico F. Reconciling Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/node/49780/psn-pdf
January 01, 2017 - The Missing Abscess: Radiology Reads in the Digital Era
January 1, 2017
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
Case Objectives
Identify the most common complication of hysterectomy.
Descr…
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - But we're worried that the error might be disseminated more broadly, outside the walls of the institution
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psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - gained wide acceptance, and in some hospitals patients have been placed on key committees throughout the institution—a
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psnet.ahrq.gov/issue/medication-errors-2nd-ed
March 29, 2007 - Book/Report
Classic
Medication Errors. 2nd ed.
Citation Text:
Medication Errors. 2nd ed. Cohen MR, ed. Washington DC: American Pharmacists Association; 2007.
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