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psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
November 16, 2022 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures
Citation Text:
Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP
November 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/perspective/conversation-michael-l-millenson
April 27, 2022 - In Conversation With... Michael L. Millenson
April 27, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Michael L. Millenson. PSNet [internet]. 2022.In Conversation With... Michael L. Millenson. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/issue/solving-puzzle-improving-safety-outcomes
September 07, 2022 - Commentary
Solving the puzzle: improving safety outcomes.
Citation Text:
Solving the puzzle: improving safety outcomes. Whitehouse D. Br J Healthc Manage. 2013;19(9):446-448.
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psnet.ahrq.gov/issue/second-trial
November 08, 2017 - Multi-use Website
The SECOND Trial
Citation Text:
The SECOND Trial Northwestern University Feinberg School of Medicine
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - An institutional culture that encourages communication among all members of the health care team can
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - This is an area with evolving evidence as imaging technology as well as institutional experience and
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psnet.ahrq.gov/node/49852/psn-pdf
February 01, 2019 - Triaging Interhospital Transfers
February 1, 2019
Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
Case Objectives
Recognize that transfer of patients between acute care hospitals is common.
Realize that the interhospital transfer…
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - SPOTLIGHT CASE
Errors in Sepsis Management
Citation Text:
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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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/triaging-interhospital-transfers
April 12, 2023 - SPOTLIGHT CASE
Triaging Interhospital Transfers
Citation Text:
Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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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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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/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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psnet.ahrq.gov/issue/check-safety-culture-my-patient-care-area
December 22, 2010 - Tools/Toolkit
A check-up for safety culture in "my patient care area."
Citation Text:
Sexton JB, Paine LA, Manfuso J, et al. A Check-up for Safety Culture in “My Patient Care Area”. doi:10.1016/s1553-7250(07)33081-x.
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psnet.ahrq.gov/perspective/update-safety-culture
January 22, 2020 - Update on Safety Culture
Allan Frankel, MD, and Michael Leonard, MD | August 22, 2013
View more articles from the same authors.
Citation Text:
Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qual…
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - Reconciling Records
November 1, 2010
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/reconciling-records
The Cases
Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local
teaching hospital. When discharged, h…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.338_slideshow.ppt
January 01, 2015 - PowerPoint Presentation
Spotlight
Monitoring Fetal Health
1
This presentation is based on the January 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Mark W. Scerbo, PhD, Department of Psychology, Old Dominion University, and Alfred Z. Abuham…
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - Detection of Safety Hazards
September 15, 2024
Detection of Safety Hazards. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/detection-safety-hazards
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient s…