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psnet.ahrq.gov/node/39423/psn-pdf
June 02, 2010 - Triggers for emergency team activation: a multicenter
assessment.
June 2, 2010
Chen J, Bellomo R, Hillman K, et al. Triggers for emergency team activation: a multicenter assessment. J
Crit Care. 2010;25(2):359.e1-7. doi:10.1016/j.jcrc.2009.12.011.
https://psnet.ahrq.gov/issue/triggers-emergency-team-activation-mul…
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psnet.ahrq.gov/node/48074/psn-pdf
August 14, 2019 - Identifying potential prescribing safety indicators related
to mental health disorders and medications: a systematic
review.
August 14, 2019
Khawagi WY, Steinke DT, Nguyen J, et al. Identifying potential prescribing safety indicators related to
mental health disorders and medications: A systematic review. PLoS One…
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psnet.ahrq.gov/node/836758/psn-pdf
March 16, 2022 - Internet of things in healthcare for patient safety: an
empirical study.
March 16, 2022
Yesmin T, Carter MW, Gladman AS. Internet of things in healthcare for patient safety: an empirical study.
BMC Health Serv Res. 2022;22(1):278. doi:10.1186/s12913-022-07620-3.
https://psnet.ahrq.gov/issue/internet-things-healthc…
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psnet.ahrq.gov/node/41761/psn-pdf
October 17, 2012 - The lost sponge: patient safety in the operating room.
October 17, 2012
Grant-Orser A, Davies P, Singh SS. The lost sponge: patient safety in the operating room. CMAJ .
2012;184(11):1275-1278. doi:10.1503/cmaj.110900.
https://psnet.ahrq.gov/issue/lost-sponge-patient-safety-operating-room
This commentary reviews th…
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psnet.ahrq.gov/node/46039/psn-pdf
April 05, 2017 - Retained lumbar catheter tip.
April 5, 2017
DeLancey JO, Barnard C, Bilimoria KY. Retained Lumbar Catheter Tip. JAMA. 2017;317(12):1269-1270.
doi:10.1001/jama.2017.1713.
https://psnet.ahrq.gov/issue/retained-lumbar-catheter-tip
Retained surgical items are considered a sentinel event. Discussing an incident involvi…
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psnet.ahrq.gov/node/43443/psn-pdf
August 13, 2014 - Feds stop public disclosure of many serious hospital
errors.
August 13, 2014
O'Donnell J.
https://psnet.ahrq.gov/issue/feds-stop-public-disclosure-many-serious-hospital-errors
This newspaper article reports on changes to publicly reported data on the Hospital Compare Web site.
Several avoidable hospital-acquired …
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psnet.ahrq.gov/node/859299/psn-pdf
December 20, 2023 - Interprofessional staff perspectives on the adoption of OR
black box technology and simulations to improve patient
safety: a multi-methods survey.
December 20, 2023
Campbell K, Gardner A, Scott DJ, et al. Interprofessional staff perspectives on the adoption of or black box
technology and simulations to improve pat…
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psnet.ahrq.gov/node/33583/psn-pdf
March 01, 2023 - The learning objectives of the simulation should drive the simulation methods used.
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psnet.ahrq.gov/node/44789/psn-pdf
April 25, 2016 - Guideline for prevention of retained surgical items.
April 25, 2016
Putnam K. Guideline for prevention of retained surgical items. AORN J. 2015;102(6):P11-P13.
https://psnet.ahrq.gov/issue/guideline-prevention-retained-surgical-items
Retained surgical items are considered a sentinel event in perioperative care. Thi…
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psnet.ahrq.gov/node/73529/psn-pdf
July 28, 2021 - Prevalence and characteristics of interruptions and
distractions during surgical counts.
July 28, 2021
Bubric KA, Biesbroek SL, Laberge JC, et al. Prevalence and characteristics of interruptions and distractions
during surgical counts. Jt Comm J Qual Patient Saf. 2021;47(9):556-562. doi:10.1016/j.jcjq.2021.05.004.
…
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psnet.ahrq.gov/node/866745/psn-pdf
September 18, 2024 - State of the Science and Future Directions to Improve
Diagnostic Safety in Older Adults.
September 18, 2024
Tran AK, Syed Q, Bierman AS, et al. State Of The Science And Future Directions To Improve Diagnostic
Safety In Older Adults. Rockville, MD: Agency for Healthcare Research and Quality; September 2024.
AHRQ Pu…
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - Case Objectives
Describe risk factors for poor outcome in patients with gastrointestinal bleeding … PubMedId RIS
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February 14, 2018 - Case Objectives Define alarm fatigue and describe potential errors that can occur due to alarm fatigue … PubMedId RIS
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psnet.ahrq.gov/web-mm/perils-contrast-media
March 01, 2007 - Case Objectives
Recognize that contrast media are potentially nephrotoxic. … PubMedId RIS
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - Case Objectives
Describe the rationale for disclosing harmful errors to patients. … PubMedId RIS
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August 21, 2007 - https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
Case Objectives
Appreciate that … psnet.ahrq.gov//#references
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November 23, 2016 - Case Objectives Explore the benefits of the continuity of hospital care. … PubMedId RIS
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February 17, 2011 - Case Objectives Assess risk for venous thromboembolism (VTE) in hospitalized patients List recommended … PubMedId RIS
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January 18, 2013 - Case Objectives State that emergency surgery is high risk and has high mortality. … PubMedId RIS
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psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
January 03, 2017 - Case Objectives
Understand types and frequencies of adverse events occurring between patient discharge … PubMedId RIS
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