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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50615/psn-pdf
    October 30, 2019 - Misidentifying the Unidentified – John Doe and the EHR October 30, 2019 Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr The Case  Two male patients of similar age arrived at the same …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49416/psn-pdf
    September 01, 2003 - Check the Bags September 1, 2003 Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/check-bags The Case A 50-year-old man with new atrial fibrillation was placed on a diltiazem drip in the emergency department for rate control. After arriving at the cardiac care unit (CCU…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33755/psn-pdf
    September 01, 2013 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety September 1, 2013 Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/what-weve-learned-ab…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49511/psn-pdf
    May 01, 2006 - Citrate Mix-Up May 1, 2006 Weber RJ. Citrate Mix-Up. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/citrate-mix The Case A 36-year-old woman with multiple sclerosis, diabetes, and chronic renal failure was transferred from a skilled nursing facility (SNF) to the hospital for treatment of an infection. On a…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50844/psn-pdf
    January 29, 2020 - Improving Patient Safety and Team Communication through Daily Huddles January 29, 2020 Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. 2020. https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles Background Communicat…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33606/psn-pdf
    December 15, 2024 - Opioid Safety December 15, 2024 Opioid Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/opioid-safety 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 safety field. Last reviewed in 2024. Bac…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33713/psn-pdf
    June 01, 2011 - The Safety of Medical Devices June 1, 2011 Nemeth CP. The Safety of Medical Devices. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/safety-medical-devices Perspective Edward Tenner is right. Technology does have reverberations, including unintended consequences, or "revenge effects."(1) While such dra…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73905/psn-pdf
    October 06, 2021 - Health Equity and Maternal Health October 6, 2021 Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/health-equity-and-maternal-health Redefining Maternal Safety Maternal safety refers to the safety of a person during pregnancy, childb…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33641/psn-pdf
    November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again November 1, 2006 Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again Perspective Certain phrases ar…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33854/psn-pdf
    March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety March 1, 2018 Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety Perspective Errors in hospitals remain a major cause of death.(1…
  11. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
    February 01, 2017 - PowerPoint Presentation Spotlight The Hazards of Distraction: Ticking All the EHR Boxes * Source and Credits This presentation is based on the February 2017 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
  12. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
    October 01, 2011 - Spotlight Case [MONTH] 2003 Spotlight Case Mobility Lost in the ICU * * Source and Credits This presentation is based on the October 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jim Smith, PT, DPT, MA; Associate Professor of Physical …
  13. psnet.ahrq.gov/primer/high-reliability
    January 29, 2020 - High Reliability Citation Text: High Reliability. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downl…
  14. psnet.ahrq.gov/primer/human-factors-engineering
    December 15, 2024 - Human Factors Engineering Citation Text: Human Factors Engineering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
  15. psnet.ahrq.gov/primer/triggers-and-trigger-tools
    September 15, 2024 - Triggers and Trigger Tools Citation Text: Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
  16. psnet.ahrq.gov/innovation/team-developed-care-plan-and-ongoing-care-management-social-workers-and-nurse
    July 23, 2024 - Results have shown reductions in hospital readmission rates (to <10%) at both institutions and greater
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837958/psn-pdf
    December 01, 2021 - perform an MSE.7  The MSE has traditionally been performed by an emergency medicine physician, but some institutions
  18. psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
    July 31, 2023 - Healthcare facilities may share information and lessons learned within their own institutions and system
  19. psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
    August 01, 2006 - Some institutions and administrators now resist the instinct to blame first and ask questions later.
  20. psnet.ahrq.gov/perspective/conversation-cindy-brach
    December 27, 2019 - personal identification, language, thoughts, communications, actions, customs, beliefs, values, and institutions

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