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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest
Citation Text:
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…
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psnet.ahrq.gov/curated-library/nurse-wellbeing-and-patient-safety
August 30, 2023 - Breadcrumb
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Created By: Lorri Zipperer, Cybrarian, AHRQ…
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - Nursing and Patient Safety
Citation Text:
Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/issue/when-things-go-wrong-voices-patients-and-families
November 19, 2015 - Audiovisual
When Things Go Wrong: Voices of Patients and Families.
Citation Text:
When Things Go Wrong: Voices of Patients and Families. CRICO/RMF; Harvard Risk Management Foundation
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psnet.ahrq.gov/issue/being-open-communicating-patient-safety-incidents-patients-and-their-carers
October 26, 2007 - Multi-use Website
Being open: communicating patient safety incidents with patients and their carers.
Citation Text:
Being open: communicating patient safety incidents with patients and their carers. National Patient Safety Agency.
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psnet.ahrq.gov/issue/patients-and-families-teachers-mixed-methods-assessment-collaborative-learning-model-medical
July 12, 2017 - Study
Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention.
Citation Text:
Langer T, Martinez W, Browning DM, et al. Patients and families as teachers: a mixed methods assessment of a collaborative lea…
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psnet.ahrq.gov/node/41051/psn-pdf
February 20, 2012 - What do patients and relatives know about problems and
failures in care?
February 20, 2012
Iedema R, Allen S, Britton K, et al. What do patients and relatives know about problems and failures in
care? BMJ Qual Saf. 2012;21(3):198-205. doi:10.1136/bmjqs-2011-000100.
https://psnet.ahrq.gov/issue/what-do-patients-and…
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psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
February 01, 2012 - by the nurse in charge of the patient, and all the involved teams are expected to have at least one member
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psnet.ahrq.gov/node/42535/psn-pdf
October 16, 2013 - Implementing an interprofessional patient safety learning
initiative: insights from participants, project leads and
steering committee members.
October 16, 2013
Jeffs L, Abramovich IA, Hayes C, et al. Implementing an interprofessional patient safety learning initiative:
insights from participants, project leads an…
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psnet.ahrq.gov/node/40275/psn-pdf
March 23, 2011 - Discrepant perceptions of communication, teamwork and
situation awareness among surgical team members.
March 23, 2011
Wauben LSGL, van Doorn CMD-, van Wijngaarden JDH, et al. Discrepant perceptions of communication,
teamwork and situation awareness among surgical team members. Int J Qual Health Care.
2011;23(2):15…
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psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - The Missing Suction Tip
November 1, 2003
Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missing-suction-tip
Case Objectives
Identify the risk factors for retained foreign bodies.
Understand methods used to prevent and identify retained foreign bodies.
Apprecia…
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psnet.ahrq.gov/node/47555/psn-pdf
November 14, 2018 - How one hospital improved patient safety in 10 minutes a
day.
November 14, 2018
van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.
https://psnet.ahrq.gov/issue/how-one-hospital-improved-patient-safety-10-minutes-day
Aviation continues to provide inspiration for patient safety innovation. This commentar…
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psnet.ahrq.gov/node/34839/psn-pdf
April 06, 2011 - Communication failures in the operating room: an
observational classification of recurrent types and
effects.
April 6, 2011
Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational
classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330-4.
http…
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psnet.ahrq.gov/node/45031/psn-pdf
February 18, 2017 - Information transfer in multidisciplinary operating room
teams: a simulation-based observational study.
February 18, 2017
Cumin D, Skilton C, Weller J. Information transfer in multidisciplinary operating room teams: a simulation-
based observational study. BMJ Qual Saf. 2017;26(3):209-216. doi:10.1136/bmjqs-2015-00…
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psnet.ahrq.gov/node/42638/psn-pdf
October 09, 2013 - Strengths and weaknesses of working with the Global
Trigger Tool method for retrospective record review:
focus group interviews with team members.
October 9, 2013
Schildmeijer K, Nilsson L, Perk J, et al. Strengths and weaknesses of working with the Global Trigger Tool
method for retrospective record review: focus…
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psnet.ahrq.gov/perspective/conversation-dave-debronkart
June 01, 2014 - Or the many tragedies where we hear about when a clinician becomes a patient or a family member, and
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psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
April 01, 2009 - He has published several seminal papers and was a member of the team that authored the IOM report, "To
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psnet.ahrq.gov/perspective/safety-radiology
October 01, 2013 - It's a way of looking at dose that every hospital, every facility, every single person, every 5000-member
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - for submassive PE
and activation of the pulmonary embolism response team (PERT), which includes a member
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psnet.ahrq.gov/perspective/conversation-susan-smith-md
August 01, 2019 - median, we took the cost of the scribes and running the program, figured out what it costs per faculty member