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psnet.ahrq.gov/issue/meta-review-methods-measuring-and-monitoring-safety-primary-care
November 03, 2021 - Review
A meta-review of methods of measuring and monitoring safety in primary care.
Citation Text:
O’Connor P, Madden C, O’Dowd E, et al. A meta-review of methods of measuring and monitoring safety in primary care. Int J Qual Health Care. 2021;33(3):mzab117. doi:10.1093/intqhc/mzab117.
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psnet.ahrq.gov/primer/teamwork-training
September 15, 2024 - Teamwork Training
Citation Text:
Teamwork Training. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Dow…
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psnet.ahrq.gov/curated-library/rapid-response-systems
September 15, 2024 - Breadcrumb
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Created By: AHRQ
Date Created: January 24, 20…
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psnet.ahrq.gov/node/33721/psn-pdf
November 01, 2011 - Lesson from the VA's Team Training Program
November 1, 2011
Neily J, Mills PD, Paull DE, et al. Lesson from the VA's Team Training Program . PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/lesson-vas-team-training-program
Perspective
Introduction
The Veterans Health Administration (VHA) National Center…
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psnet.ahrq.gov/node/836978/psn-pdf
May 16, 2022 - Check Twice, Transport Once
May 16, 2022
DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/check-twice-transport-once
The Case
Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal
pain and was diagnosed with “s…
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psnet.ahrq.gov/web-mm/privacy-gone-awry
February 24, 2011 - Privacy Gone Awry
Citation Text:
Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
September 29, 2021 - SPOTLIGHT CASE
Intraosseous Line Extravasation in a Pediatric Trauma Patient
Citation Text:
Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/node/38410/psn-pdf
January 23, 2012 - A towel with a safety message.
January 23, 2012
Lerner M.
https://psnet.ahrq.gov/issue/towel-safety-message
This newspaper article highlights a simple innovation one hospital is using to trigger a time out in the
operating room.
https://psnet.ahrq.gov/issue/towel-safety-message
https://psnet.ahrq.gov//#timeouts
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psnet.ahrq.gov/node/35519/psn-pdf
July 24, 2008 - Bringing surgeons down to earth.
July 24, 2008
Landro L.
https://psnet.ahrq.gov/issue/bringing-surgeons-down-earth
This article reports on several pilot initiatives designed to improve safety culture in the operating room.
https://psnet.ahrq.gov/issue/bringing-surgeons-down-earth
https://psnet.ahrq.gov//#safetycul…
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psnet.ahrq.gov/node/40877/psn-pdf
February 05, 2018 - Fire Safety.
February 5, 2018
Council on Surgical & Perioperative Safety.
https://psnet.ahrq.gov/issue/fire-safety
This initiative provides information on surgical fires and makes recommendations to address the risk of fires
during surgery.
https://psnet.ahrq.gov/issue/fire-safety
https://psnet.ahrq.gov/issue/pra…
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psnet.ahrq.gov/node/35903/psn-pdf
May 04, 2015 - Costly issues of an uncommunicative OR.
May 4, 2015
Neil R. Costly issues of an uncommunicative OR. Materials management in health care. 2006;15(3):30-3.
https://psnet.ahrq.gov/issue/costly-issues-uncommunicative-or
This article discusses initiatives for better communication and teamwork in the operating room in or…
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - SPOTLIGHT CASE
The Missing Abscess: Radiology Reads in the Digital Era
Citation Text:
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - SPOTLIGHT CASE
Transfer Troubles
Citation Text:
Hains IM. Transfer Troubles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - A Double “Never Event”: Wrong Patient and Wrong Side.
Citation Text:
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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…
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
March 27, 2024
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and
Emergency Hysterectomy. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
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psnet.ahrq.gov/node/49774/psn-pdf
November 01, 2016 - Don't Dismiss the Dangerous: Obstetric Hemorrhage
November 1, 2016
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
Case Objectives
List the common causes of obstetric hemorrhage and the need for a unit-sta…
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psnet.ahrq.gov/issue/probabilistic-risk-assessment-accidental-abo-incompatible-thoracic-organ-transplantation-and
June 24, 2020 - Study
Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.
Citation Text:
Cook RI, Wreathall J, Smith A, et al. Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 200…
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psnet.ahrq.gov/issue/double-checking-administration-medicines-what-evidence-systematic-review
June 18, 2014 - Review
Double checking the administration of medicines: what is the evidence? A systematic review.
Citation Text:
Alsulami Z, Conroy S, Choonara I. Double checking the administration of medicines: what is the evidence? A systematic review. Arch Dis Child. 2012;97(9):833-7. doi:10.1136/a…
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psnet.ahrq.gov/issue/risk-factors-adverse-events-emergency-department-procedural-sedation-children
January 19, 2014 - Study
Risk factors for adverse events in emergency department procedural sedation for children.
Citation Text:
Bhatt M, Johnson DW, Chan J, et al. Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr. 2017;171(10):957-964. doi:10.1001/jam…
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psnet.ahrq.gov/issue/use-emergency-manual-during-intraoperative-cardiac-arrest-interprofessional-team-positive
April 03, 2019 - Study
Use of an emergency manual during an intraoperative cardiac arrest by an interprofessional team: a positive-exemplar case study of a new patient safety tool.
Citation Text:
Merrell SB, Gaba DM, Agarwala A, et al. Use of an Emergency Manual During an Intraoperative Cardiac Arrest by…