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psnet.ahrq.gov/issue/white-paper-recommendation-systems-based-practice-competency
December 18, 2017 - Commentary
White paper on recommendation for systems-based practice competency.
Citation Text:
Stalter AM, Phillips JM, Dolansky MA. QSEN Institute RN-BSN Task Force: White Paper on Recommendation for Systems-Based Practice Competency. J Nurs Care Qual. 2017;32(4):354-358. doi:10.1097/NC…
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psnet.ahrq.gov/issue/improving-patient-safety-radiology-concepts-comprehensive-patient-safety-program
December 14, 2016 - Commentary
Improving patient safety in radiology: concepts for a comprehensive patient safety program.
Citation Text:
Donnelly LF, Dickerson JM, Goodfriend MA, et al. Improving patient safety in radiology: concepts for a comprehensive patient safety program. Semin Ultrasound CT MR. 2010…
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psnet.ahrq.gov/issue/effect-electronic-checklist-critical-care-provider-workload-errors-and-performance
January 22, 2016 - Study
The effect of an electronic checklist on critical care provider workload, errors, and performance.
Citation Text:
Thongprayoon C, Harrison AM, O'Horo JC, et al. The Effect of an Electronic Checklist on Critical Care Provider Workload, Errors, and Performance. J Intensive Care Med. …
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psnet.ahrq.gov/issue/impact-senior-clinical-review-patient-disposition-emergency-department
August 28, 2024 - Study
Impact of senior clinical review on patient disposition from the emergency department.
Citation Text:
White AL, Armstrong PAR, Thakore S. Impact of senior clinical review on patient disposition from the emergency department. Emerg Med J. 2010;27(4):262-5, 296. doi:10.1136/emj.200…
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psnet.ahrq.gov/issue/strategies-enhance-adoption-ventilator-associated-pneumonia-prevention-interventions
July 10, 2017 - Review
Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: a systematic literature review.
Citation Text:
Goutier JM, Holzmueller CG, Edwards KC, et al. Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: a s…
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psnet.ahrq.gov/issue/implementing-perioperative-handoff-tool-improve-postprocedural-patient-transfers
February 29, 2012 - Commentary
Implementing a perioperative handoff tool to improve postprocedural patient transfers.
Citation Text:
Petrovic MA, Martinez EA, Aboumatar HJ. Implementing a perioperative handoff tool to improve postprocedural patient transfers. Jt Comm J Qual Patient Saf. 2012;38(3):135-42.
…
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psnet.ahrq.gov/issue/improving-quality-health-care-whats-taking-so-long
April 06, 2016 - Commentary
Classic
Improving the quality of health care: what's taking so long?
Citation Text:
Chassin MR. Improving The Quality Of Health Care: What’s Taking So Long? Health Aff. 2013;32(10):1761-1765. doi:10.1377/hlthaff.2013.0809.
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psnet.ahrq.gov/issue/transforming-healthcare-safety-imperative
June 26, 2019 - Commentary
Classic
Transforming healthcare: a safety imperative.
Citation Text:
Leape L, Berwick D, Clancy C, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care. 2009;18(6):424-8. doi:10.1136/qshc.2009.036954.
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…
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psnet.ahrq.gov/issue/operating-room-briefings-and-wrong-site-surgery
November 26, 2008 - Study
Classic
Operating room briefings and wrong-site surgery.
Citation Text:
Makary MA, Mukherjee A, Sexton B, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204(2):236-43.
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psnet.ahrq.gov/issue/transforming-concepts-patient-safety-progress-report
January 20, 2015 - Review
Classic
Transforming concepts in patient safety: a progress report.
Citation Text:
Gandhi TK, Kaplan GS, Leape L, et al. Transforming concepts in patient safety: a progress report. BMJ Qual Saf. 2018;27(12):1019-1026. doi:10.1136/bmjqs-2017-007756.
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psnet.ahrq.gov/issue/diagnostic-reasoning-endangered-competency-internal-medicine-training
September 04, 2019 - Commentary
Diagnostic reasoning: an endangered competency in internal medicine training.
Citation Text:
Simpkin AL, Vyas JM, Armstrong KA. Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training. Ann Intern Med. 2017;167(7):507-508. doi:10.7326/M17-0163.
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psnet.ahrq.gov/node/33893/psn-pdf
February 19, 2010 - The revolutionary.
February 19, 2010
Swidey N.
https://psnet.ahrq.gov/issue/revolutionary
An introduction to Donald Berwick, CEO of Boston's Institute for Healthcare Improvement, and his vision for
reshaping health care to improve patient safety and quality.
https://psnet.ahrq.gov/issue/revolutionary
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psnet.ahrq.gov/node/33610/psn-pdf
April 01, 2005 - Introducing the New AHRQ WebM&M and AHRQ Patient
Safety Network (PSNet)
April 1, 2005
Wachter R. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet). PSNet
[internet]. 2005.
https://psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
Editorial
Five year…
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psnet.ahrq.gov/node/49817/psn-pdf
January 01, 2018 - Slow Down: Right Drug, Wrong Formulation
January 1, 2018
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
The Case
A 65-year-old man presented to his primary care clinic for follow-up after a recent hospitaliz…
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psnet.ahrq.gov/node/33731/psn-pdf
June 01, 2012 - An American View of the UK's Patient Safety Enterprise:
Top Down vs. Bottom Up
June 1, 2012
Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
Perspecti…
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psnet.ahrq.gov/node/49775/psn-pdf
November 01, 2016 - Unexpected Drawbacks of Electronic Order Sets
November 1, 2016
McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
The Case
A 70-year-old man with stage 4 prostate cancer presented to the emergency department …
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psnet.ahrq.gov/node/49489/psn-pdf
September 01, 2005 - Double Trouble
September 1, 2005
Gurwitz JH. Double Trouble. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/double-trouble
Case Objectives
Appreciate the incidence of adverse drug events in older persons
List preventative measures that can be used to minimize medication errors in this population
Encourage…
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psnet.ahrq.gov/node/33675/psn-pdf
October 01, 2008 - Identifying Adverse Events Not Present on Admission:
Can We Do It?
October 1, 2008
Naessens JM. Identifying Adverse Events Not Present on Admission: Can We Do It? PSNet [internet].
2008.
https://psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
Perspective
Interest is growi…
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psnet.ahrq.gov/node/60330/psn-pdf
May 05, 2020 - Telehealth and Patient Safety During the COVID-19
Response
May 14, 2020
Sikka N, Willis JS, Fitall E, et al. Telehealth and Patient Safety During the COVID-19 Response. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
Introduction
Telehealth typ…
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psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
February 01, 2014 - Wrong-Time Error With High-Alert Medication
Citation Text:
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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