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psnet.ahrq.gov/issue/operating-management-system-high-reliability-leadership-accountability-learning-and
July 01, 2016 - Commentary
Operating management system for high reliability: leadership, accountability, learning and innovation in healthcare.
Citation Text:
Day RM, Demski RJ, Pronovost PJ, et al. Operating management system for high reliability: Leadership, accountability, learning and innovation in …
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psnet.ahrq.gov/issue/pain-management-and-prescription-opioid-related-harms-exploring-state-evidence-proceedings
July 05, 2008 - Meeting/Conference Proceedings
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.
Citation Text:
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Works…
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psnet.ahrq.gov/issue/paradoxical-effects-hospital-based-multi-intervention-programme-aimed-reducing-medication
September 13, 2023 - Study
Paradoxical effects of a hospital-based, multi-intervention programme aimed at reducing medication round interruptions.
Citation Text:
Tomietto M, Sartor A, Mazzocoli E, et al. Paradoxical effects of a hospital-based, multi-intervention programme aimed at reducing medication round …
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psnet.ahrq.gov/issue/alarm-management-first-things-first-using-reliable-data-eliminate-unnecessary-alarms
July 29, 2009 - Newspaper/Magazine Article
Alarm management: first things first: using reliable data to eliminate unnecessary alarms.
Citation Text:
Alarm management: first things first: using reliable data to eliminate unnecessary alarms. Vanderveen T. Patient Saf Qual Healthc. November/December 2014;1…
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psnet.ahrq.gov/node/42168/psn-pdf
November 21, 2021 - Surviving Sepsis Campaign: international guidelines for
management of sepsis and septic shock: 2021.
November 21, 2021
Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for
Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021;49(11):e1063-e1143.
doi:10.1097/ccm.0…
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psnet.ahrq.gov/issue/strategies-prevent-missed-nursing-care-international-qualitative-study-based-upon-positive
May 18, 2022 - Study
Strategies to prevent missed nursing care: an international qualitative study based upon a positive deviance approach.
Citation Text:
Longhini J, Papastavrou E, Efstathiou G, et al. Strategies to prevent missed nursing care: an international qualitative study based upon a positive …
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psnet.ahrq.gov/node/867004/psn-pdf
October 30, 2024 - Critical Radiology Alert Process
October 30, 2024
https://psnet.ahrq.gov/innovation/critical-radiology-alert-process
Summary
Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of
unrelated abnormal findings and provides a companion follow-up process, with the goal o…
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psnet.ahrq.gov/issue/high-performance-work-systems-health-care-management-part-1-and-part-2
March 22, 2017 - Special or Theme Issue
High-Performance Work Systems in Health Care Management: Parts 1-5.
Citation Text:
High-Performance Work Systems in Health Care Management: Parts 1-5. Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.
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…
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psnet.ahrq.gov/node/60990/psn-pdf
October 07, 2020 - Tiered daily huddles: the power of teamwork in managing
large healthcare organisations.
October 7, 2020
Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ
Qual Saf. 2020;29(12):1050-1052. doi:10.1136/bmjqs-2019-010575.
https://psnet.ahrq.gov/issue/tiered-daily…
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psnet.ahrq.gov/issue/promoting-patient-safety-through-effective-health-information-technology-risk-management
May 25, 2016 - Government Resource
Promoting Patient Safety Through Effective Health Information Technology Risk Management.
Citation Text:
Promoting Patient Safety Through Effective Health Information Technology Risk Management. Schneider EC, Ridgely MS, Meeker D, Hunter LE, Khodyakov D, Rudin R. RAND…
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psnet.ahrq.gov/issue/impact-introducing-automated-dispensing-cabinets-barcode-medication-administration-and-closed
March 10, 2021 - Review
Emerging Classic
The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: a systematic review.
C…
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psnet.ahrq.gov/issue/moving-towards-safety-ii-approach
May 18, 2022 - Commentary
Moving towards a Safety II approach.
Citation Text:
Woodward S. Moving towards a safety II approach. J Patient Saf Risk Manag. 2019;24(3):96-99. doi:10.1177/2516043519855264.
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Format:
DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/node/838133/psn-pdf
January 01, 2023 - Nurse managers' leadership, patient safety, and quality of
care: a systematic review.
September 21, 2022
Lee SE, Hyunjie L, Sang S. Nurse managers' leadership, patient safety, and quality of care: a systematic
review. West J Nurs Res. 2023;45(2):176-185. doi:10.1177/01939459221114079.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
Citation Text:
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia
Citation Text:
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - SPOTLIGHT CASE
Patient Safety Events Involving Opioid Dose Stacking
Citation Text:
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/74239/psn-pdf
January 12, 2022 - Evaluation of clinical practice guidelines on fall
prevention and management for older adults: a
systematic review.
January 12, 2022
Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, et al. Evaluation of clinical practice guidelines on fall
prevention and management for older adults: a systematic review. JAMA Netw …
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psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
July 31, 2023 - Procedure Complications – Who is Responsible for Follow up?
Citation Text:
Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/issue/negative-behaviours-health-care-prevalence-and-strategies
May 01, 2024 - Study
Negative behaviours in health care: prevalence and strategies.
Citation Text:
Layne DM, Nemeth LS, Mueller M, et al. Negative behaviours in health care: Prevalence and strategies. J Nurs Manag. 2019;27(1):154-160. doi:10.1111/jonm.12660.
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Format:
DOI Goog…
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Patient Safety Events Involving Opioid
Dose Stacking
Source and Credits
• This presentation is based on the January 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…