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psnet.ahrq.gov/node/49512/psn-pdf
May 01, 2006 - Right? Left? Neither!
May 1, 2006
Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-left-neither
Case Objectives
Appreciate the role of Reason's Swiss Cheese Model in medical errors
Understand the process of analyzing a single error
Provide suggestions for …
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psnet.ahrq.gov/web-mm/hiding-plain-sight
April 24, 2019 - Hiding in Plain Sight
Citation Text:
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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psnet.ahrq.gov/node/846171/psn-pdf
July 26, 2022 - Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
March 15, 2023
Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of
Gastric Perforation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/agitated-delirium-contributes…
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www.ahrq.gov/patient-safety/reports/advancing/index.html
July 01, 2022 - Advancing Patient Safety
A Decade of Evidence, Design, and Implementation
After the Institute of Medicine released its sentinel report, To Err is Human: Building a Safer Health System , the Agency for Healthcare Research and Quality (AHRQ), in conjunction with its Federal partners and non-Federal…
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - In Conversation With... Heidi Wald, MD
November 26, 2019
Also Read the Essay
Citation Text:
In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.In Conversation With... Heidi Wald, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - Patient Safety in Frail Older Patients
November 26, 2019
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. Rockville (MD): Agency for Healthc…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs028511-held-final-report-2024.pdf
January 01, 2024 - A Machine Learning Health System to Integrate Care for Substance Misuse and HIV Treatment and Prevention among Hospitalized Patients - Final Report
2024
A Machine Learning Health System to
Integrate Care for Substance Misuse and HIV
Treatment and Prevention among
Ho…
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - SPOTLIGHT CASE
Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough
Citation Text:
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/node/45769/psn-pdf
December 21, 2016 - National Scorecard on Rates of Hospital-Acquired
Conditions 2010 to 2015: Interim Data From National
Efforts to Make Health Care Safer.
December 21, 2016
Rockville, MD: Agency for Healthcare Research and Quality; December 2016.
https://psnet.ahrq.gov/issue/national-scorecard-rates-hospital-acquired-conditions-2010…
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www.ahrq.gov/hai/cauti-tools/impl-guide/implementation-guide-appendix-e.html
October 01, 2015 - Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Appendix E. Poster on Urinary Catheter Risks and Indications
Previous Page Next Page
Table of Contents
Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Imple…
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www.ahrq.gov/ncepcr/tools/obesity-kit/obtoolkit-tool15.html
March 01, 2014 - Community Connections: Linking Primary Care Patients to Local Resources for Better Management of Obesity
Community Connections: Linking Primary Care Patients to Local Resources for Better Management of Obesity
Previous Page Next Page
Table of Contents
Community Connections: Linking Primary Care Pati…
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www.ahrq.gov/teamstepps-program/curriculum/situation/tools/monitoring.html
June 01, 2023 - Tool: Cross-Monitoring
Ongoing cross‐monitoring of the care environment helps everyone recognize risks and errors. It allows individuals and teams to take steps to correct the issue before harm or injury to the patient occurs. As one example, e-ICUs have proven the value of having remote staff cross-monitoring …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/112-who-task-evc-monitoring-one-pager.docx
April 01, 2025 - Who Should Take On the Task of Environmental Cleaning Monitoring?
Surgical Services
When planning an environmental cleaning (EVC) monitoring program, it is crucial to decide who should carry out the monitoring. This document evaluates various roles suitable for the task and outlines the advantages and disadvantages.
Ef…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/handouts/patient-chg-bathing.docx
March 01, 2022 - CHG Bathing
Patients With Devices: Prevent Infections During Your Hospital Stay PATIENTSection 10-7
BATHE Daily With Chlorhexidine (CHG) Cloths
AHRQ Pub. No. 20(22)-0036
March 2022
During your stay, bathing will occur every day with a special antiseptic (CHG) that removes germs and prevents infection better t…
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psnet.ahrq.gov/node/48007/psn-pdf
May 21, 2019 - Structured override reasons for drug–drug interaction
alerts in electronic health records.
May 21, 2019
Wright A, McEvoy D, Aaron S, et al. Structured override reasons for drug-drug interaction alerts in
electronic health records. J Am Med Info Asso. 2019;26(10):934-942. doi:10.1093/jamia/ocz033.
https://psnet.ahr…
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psnet.ahrq.gov/node/42966/psn-pdf
November 21, 2018 - The next organizational challenge: finding and addressing
diagnostic error.
November 21, 2018
Graber ML, Trowbridge RL, Myers JS, et al. The next organizational challenge: finding and addressing
diagnostic error. Jt Comm J Qual Patient Saf. 2014;40(3):102-10.
https://psnet.ahrq.gov/issue/next-organizational-challe…
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psnet.ahrq.gov/node/38733/psn-pdf
July 13, 2009 - Full implementation of computerized physician order
entry and medication-related quality outcomes: a study of
3364 hospitals.
July 13, 2009
Yu FB, Menachemi N, Berner ES, et al. Full implementation of computerized physician order entry and
medication-related quality outcomes: a study of 3364 hospitals. Am J Med Qu…
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psnet.ahrq.gov/node/46504/psn-pdf
February 22, 2018 - How guiding coalitions promote positive culture change
in hospitals: a longitudinal mixed methods interventional
study.
February 22, 2018
Bradley EH, Brewster AL, McNatt Z, et al. How guiding coalitions promote positive culture change in
hospitals: a longitudinal mixed methods interventional study. BMJ Qual Saf. 2…
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psnet.ahrq.gov/node/40289/psn-pdf
March 16, 2011 - Unintentional therapeutic errors involving insulin in the
ambulatory setting reported to poison centers.
March 16, 2011
Spiller HA, Borys DJ, Ryan ML, et al. Unintentional therapeutic errors involving insulin in the ambulatory
setting reported to poison centers. Ann Pharmacother. 2011;45(1):17-22. doi:10.1345/aph.1…
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psnet.ahrq.gov/node/40024/psn-pdf
December 21, 2014 - Risk factors and outcomes for foreign body left during a
procedure: analysis of 413 incidents after 1,946,831
operations in children.
December 21, 2014
Camp M, Chang DC, Zhang Y, et al. Risk factors and outcomes for foreign body left during a procedure:
analysis of 413 incidents after 1 946 831 operations in child…