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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an
Order is Not Enough
April 28, 2021
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
Disclosure of Relev…
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psnet.ahrq.gov/node/49768/psn-pdf
September 01, 2016 - A Pill Organizing Plight
September 1, 2016
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/pill-organizing-plight
Case Objectives
Identify patients at high risk for adverse drug events.
List drugs that are considered inappropriate in older patients.
…
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psnet.ahrq.gov/web-mm/pill-organizing-plight
June 19, 2018 - SPOTLIGHT CASE
A Pill Organizing Plight
Citation Text:
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTe…
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - Critical Echocardiogram Result Lost to Follow-up
June 14, 2023
Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
The Case
A 63-year-old man with history of stroke, systolic heart failure, and ventric…
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psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.
Citation Text:
Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depa…
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psnet.ahrq.gov/node/838082/psn-pdf
September 14, 2022 - Organizational factors that promote error reporting in
healthcare: a scoping review.
September 14, 2022
Wawersik D, Palaganas J. Organizational factors that promote error reporting in healthcare: a scoping
review. J Healthc Manag. 2022;67(4):283-301. doi:10.1097/jhm-d-21-00166.
https://psnet.ahrq.gov/issue/organiz…
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psnet.ahrq.gov/node/46123/psn-pdf
January 01, 2020 - Improving patient safety in handover from intensive care
unit to general ward: a systematic review.
June 21, 2017
Wibrandt I, Lippert A. Improving Patient Safety in Handover From Intensive Care Unit to General Ward: A
Systematic Review. J Patient Saf. 2020;16(3):199-210. doi:10.1097/pts.0000000000000266.
https://p…
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psnet.ahrq.gov/node/837671/psn-pdf
July 13, 2022 - Long-term care healthcare-associated infections in 2021:
an analysis of 17,971 reports.
July 13, 2022
Kepner S, Adkins JA, Jones RM. Long-term care healthcare-associated infections in 2021: an analysis of
17,971 reports. Patient Saf. 2022;4(2):6-17. doi:10.33940/data/2022.6.1.
https://psnet.ahrq.gov/issue/long-ter…
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psnet.ahrq.gov/node/845076/psn-pdf
February 22, 2023 - Advancing diagnostic equity through clinician
engagement, community partnerships, and connected
care.
February 22, 2023
Giardina TD, Woodard LCD, Singh H. Advancing diagnostic equity through clinician engagement,
community partnerships, and connected care. J Gen Intern Med. 2023;38(5):1293-1295.
doi:10.1007/s1160…
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psnet.ahrq.gov/node/45935/psn-pdf
September 29, 2017 - Radiology research in quality and safety: current trends
and future needs.
September 29, 2017
Zygmont ME, Itri JN, Rosenkrantz AB, et al. Radiology Research in Quality and Safety: Current Trends and
Future Needs. Acad Radiol. 2017;24(3):263-272. doi:10.1016/j.acra.2016.07.021.
https://psnet.ahrq.gov/issue/radiolog…
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psnet.ahrq.gov/node/47553/psn-pdf
July 10, 2019 - Delivering high reliability in maternity care: in situ
simulation as a source of organisational resilience.
July 10, 2019
Macrae C, Draycott T. Delivering high reliability in maternity care: In situ simulation as a source of
organisational resilience. Safety Sci. 2019;117:490-500. doi:10.1016/j.ssci.2016.10.019.
h…
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psnet.ahrq.gov/node/47857/psn-pdf
June 14, 2019 - The wicked problem of patient misidentification: how
could the technological revolution help address patient
safety?
June 14, 2019
Ferguson C, Hickman L, Macbean C, et al. The wicked problem of patient misidentification: How could the
technological revolution help address patient safety? J Clin Nurs. 2019;28(13-14…
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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/node/44400/psn-pdf
September 23, 2015 - Near misses and unsafe conditions reported in a Pediatric
Emergency Research Network.
September 23, 2015
Ruddy RM, Chamberlain JM, Mahajan P, et al. Near misses and unsafe conditions reported in a Pediatric
Emergency Research Network. BMJ Open. 2015;5(9):e007541. doi:10.1136/bmjopen-2014-007541.
https://psnet.ahrq…
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psnet.ahrq.gov/node/72501/psn-pdf
November 25, 2020 - Use of an audit with feedback implementation strategy to
promote medication error reporting by nurses.
November 25, 2020
Hutchinson A, Brotto V, Chapman A, et al. Use of an audit with feedback implementation strategy to
promote medication error reporting by nurses. J Clin Nurs. 2020;29(21-22):4180-4193.
doi:10.111…
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psnet.ahrq.gov/node/48180/psn-pdf
August 21, 2019 - Burnout and Resilience and Quality and Safety Programs
in Obstetrics and Gynecology.
August 21, 2019
Main EK, Fowler JM, Gabbe SG, eds. Clin Obstet Gynecol. 2019;62:vii-xii,403-626.
https://psnet.ahrq.gov/issue/burnout-and-resilience-and-quality-and-safety-programs-obstetrics-and-
gynecology
Obstetrics is a high-…
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psnet.ahrq.gov/node/45339/psn-pdf
August 10, 2016 - Hospital at night: an organizational design that provides
safer care at night.
August 10, 2016
Hamilton-Fairley D, Coakley J, Moss F. Hospital at night: an organizational design that provides safer care
at night. BMC Med Edu. 2014;14(Suppl 1):S17. doi:10.1186/1472-6920-14-S1-S17.
https://psnet.ahrq.gov/issue/hospi…
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psnet.ahrq.gov/node/35104/psn-pdf
April 06, 2011 - Crisis management during anaesthesia: the development
of an anaesthetic crisis management manual.
April 6, 2011
Runciman WB, Kluger MT, Morris RW, et al. Crisis management during anaesthesia: the development of
an anaesthetic crisis management manual. Qual Saf Health Care. 2005;14(3):e1.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/861283/psn-pdf
January 24, 2024 - What and when to debrief: a scoping review examining
interprofessional clinical debriefing.
January 24, 2024
Paxino J, Szabo RA, Marshall SD, et al. What and when to debrief: a scoping review examining
interprofessional clinical debriefing. BMJ Qual Saf. 2024;33(5):314-327. doi:10.1136/bmjqs-2023-016730.
https://p…
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psnet.ahrq.gov/node/46480/psn-pdf
October 29, 2017 - Coaching the debriefer: peer coaching to improve
debriefing quality in simulation programs.
October 29, 2017
Cheng A, Grant V, Huffman J, et al. Coaching the Debriefer: Peer Coaching to Improve Debriefing Quality
in Simulation Programs. Simul Healthc. 2017;12(5):319-325. doi:10.1097/SIH.0000000000000232.
https://p…