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psnet.ahrq.gov/node/49832/psn-pdf
June 01, 2018 - Febrile Neutropenia and an Almost Fatal Medication Error
June 1, 2018
Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
The Case
A 33-year-old woman with recently diagnosed acute …
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psnet.ahrq.gov/node/72624/psn-pdf
January 05, 2021 - The LifePoint National Quality Program Provides
Structured Framework for Reducing Inpatient Harm
January 5, 2021
https://psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-
reducing-inpatient-harm
Summary
Building on the company’s experience as a Hospital Engagement Network…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case March 2007
Failure to Report
Source and Credits
This presentation is based on the March 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrice L. Spath, BA, RHIT, Brown-Sp…
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psnet.ahrq.gov/node/33638/psn-pdf
August 01, 2006 - Getting Into Patient Safety: A Personal Story
August 1, 2006
Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
Perspective
My journey into patient safety began in 1972. It was born of serendipity enabled by the…
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psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - Opioid Overdose as a Patient Safety Problem
May 22, 2017
Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
Perspective
Opioids serve a valuable role in the treatment of acute pain and pain associat…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
January 01, 2004 - Quantitative and Qualitative Analysis of Medication Errors: The New York Experience
131
Quantitative and Qualitative Analysis of
Medication Errors: The New York Experience
Elizabeth Duthie, Barbara Favreau, Angelo Ruperto,
Janet Mannion, Ellen Flink, Ruth Leslie
Abstract
Objectives: In June 2000, the New Yo…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/nursing-home-safety_research-protocol.pdf
July 22, 2015 - Critical Analysis of the Evidence for Patient Safety Practices in Nursing Home Settings
Evidence-based Practice Center
Project Title: Critical Analysis of …
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digital.ahrq.gov/sites/default/files/docs/page/ahrq-dhr-2022-year-in-review.pdf
January 01, 2022 - To
reduce VTE events, patients need preventive care, but guidelines for
providing preventive VTE care … Preventive Services
Task Force (USPSTF).
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/hip-fracture-booklet.pdf
November 01, 2023 - Recovering After Hip Fracture Surgery
Recovering After Hip
Fracture Surgery
e
Hip Fracture Surgery Patient Education Guide 1
Recovering After Hip Fracture Surgery
Patient Name ___________________________________________________________________
Surgeon Name _________________________________________________…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
May 01, 2023 - Improving Patient Safety in Community Pharmacies: A Resource List for Users of the AHRQ Community Pharmacy Survey on Patient Safety Culture
Improving Patient Safety in Community Pharmacies: A
Resource List for Users of the AHRQ Community
Pharmacy Survey on Patient Safety Culture
I. Purpose
This document provide…
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www.ahrq.gov/patient-safety/reports/liability/neumiller.html
August 01, 2017 - Advances in Patient Safety and Medical Liability
Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home
Previous Page
Table of Contents
Advances in Patient Safety and Medical Liability
Preface
Acknowledgments
Prologue
Silence A Commentary
…
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www.ahrq.gov/patient-safety/reports/hotline/refs.html
May 01, 2016 - Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events
References
Previous Page Next Page
Table of Contents
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events
Preface…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
May 01, 2013 - Spotlight Case July 2008
Spotlight Case
Right Regimen, Wrong Cancer: Patient Catches Medical Error
*
*
Source and Credits
This presentation is based on the May 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Joseph O. Jacobson, MD, MSc…
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pso.ahrq.gov/sites/default/files/wysiwyg/pso-brochure.pdf
March 01, 2020 - Choosing a Patient Safety Organization
Choosing a Patient Safety
Organization
Background
You are committed to making healthcare safer and
better for your patients. One of the challenges to
achieving this goal is the concern that patient safety
information that you or your organization create as
part of the ca…
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www.ahrq.gov/action-alliance/engineering-safety-practice/index.html
September 01, 2025 - Engineering Safe Practices Affinity Group
Background The National Action Alliance established the Engineering Safe Practices Affinity Group to make healthcare safer by design by identifying scalable opportunities for engineering safety into key healthcare practices—one of the Alliance’s five Aims. Read more …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4g_combo_psi10-postopmetaderangement-bestpractices.pdf
May 20, 2016 - Selected Best Practices and Suggestions for Improvement
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4g
Selected Best Practices and Suggestions for Improvement
PSI 10: Postoperative Physiologic and Metabolic Derangement
Why Focus on Postoperative Phys…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
June 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case June 2004
The Wrong Shot:
Error Disclosure
Source and Credits
This presentation is based on the June 2004
AHRQ WebM&M Spotlight Case in Pediatrics
CME credit is available through the Web site
See the full article at http://webmm.ahrq.gov
Commentary by: Thomas H. …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.14_slideshow.ppt
May 01, 2003 - PowerPoint Presentation
Spotlight Case May 2003
Central Line Complications in an Infant
webmm.ahrq.gov
Source and Credits
This presentation is based on the May 2003
AHRQ WebM&M Spotlight Case in Pediatrics
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary…
-
psnet.ahrq.gov/primer/responding-patient-safety-events
October 18, 2023 - Responding to Patient Safety Events
Citation Text:
Shaikh U. Responding to Patient Safety Events. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/node/73303/psn-pdf
May 26, 2021 - Safety Culture in EMS
May 26, 2021
Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/safety-culture-ems
Defining a Just Culture
A Just Culture is one that supports transparent and honest error reporting with the goal of fostering an
environmen…