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psnet.ahrq.gov/issue/eliminating-central-line-associated-bloodstream-infections-national-patient-safety-imperative
March 21, 2012 - Study
Eliminating central line-associated bloodstream infections: a national patient safety imperative.
Citation Text:
Berenholtz SM, Lubomski LH, Weeks K, et al. Eliminating central line-associated bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidem…
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psnet.ahrq.gov/issue/culture-change-infection-control-applying-psychological-principles-improve-hand-hygiene
November 21, 2021 - Study
Culture change in infection control: applying psychological principles to improve hand hygiene.
Citation Text:
Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013;28(4):304…
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psnet.ahrq.gov/issue/efficacy-tolerability-and-dose-dependent-effects-opioid-analgesics-low-back-pain-systematic
March 02, 2011 - Review
Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis.
Citation Text:
Shaheed CA, Maher CG, Williams KA, et al. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A S…
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psnet.ahrq.gov/issue/inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review
May 26, 2016 - Review
Inpatient fall prevention programs as a patient safety strategy: a systematic review.
Citation Text:
Miake-Lye IM, Hempel S, Ganz DA, et al. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):390-396. doi:10.732…
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psnet.ahrq.gov/issue/impact-80-hour-resident-workweek-surgical-residents-and-attending-surgeons
January 04, 2010 - Study
The impact of the 80-hour resident workweek on surgical residents and attending surgeons.
Citation Text:
Hutter MM, Kellogg KC, Ferguson CM, et al. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg. 2006;243(6):864-71; discussion 8…
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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/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - theme in many of them—that they had initially been developed, often with AHRQ's support, at a single institution
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psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
September 01, 2006 - Everybody learned from a particular person or an institution—which led to, you know, this is the Penn
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psnet.ahrq.gov/node/848124/psn-pdf
April 26, 2023 - Susan McGrath: Our institution wasn’t the first to implement continuous patient monitoring in this setting
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psnet.ahrq.gov/node/33858/psn-pdf
May 01, 2018 - the idea that it's increasingly hard to
deal with compliance and regulatory requirements as a single institution
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psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
March 27, 2024 - the idea that it's increasingly hard to deal with compliance and regulatory requirements as a single institution
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psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
February 26, 2020 - Criteria vary by institution, but patients are most often identified at triage using specific clinical
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psnet.ahrq.gov/web-mm/culture-clash-no-more-integration-and-coordination-disease-treatment-and-palliative-care
December 23, 2020 - November 3, 2015
Multiple-institution comparison of resident and faculty perceptions
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - Everybody learned from a particular person or an institution—which led to, you know, this is the Penn
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psnet.ahrq.gov/web-mm/not-miscarriage
June 01, 2005 - Not a Miscarriage
Citation Text:
Learman LA. Not a Miscarriage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
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…
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psnet.ahrq.gov/web-mm/cups-error
January 12, 2011 - Cups of Error
Citation Text:
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - Spotlight Case July 2008
Spotlight Case
Emergency Error
1
2
Source and Credits
This presentation is based on the June 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/node/863641/psn-pdf
February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training
February 28, 2024
Haugstetter M, Hines S, Sousane Z, et al. Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork…
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psnet.ahrq.gov/web-mm/situational-unawareness
August 01, 2009 - Situational (Un)Awareness
Citation Text:
Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/33838/psn-pdf
July 01, 2017 - Doctors With Multiple Malpractice Claims, Disciplinary
Actions, and Complaints: What Do We Know?
July 1, 2017
Studdert DM. Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We
Know? PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-…