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psnet.ahrq.gov/node/42978/psn-pdf
February 26, 2014 - https://psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance
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psnet.ahrq.gov/node/44700/psn-pdf
March 23, 2016 - identified various interlinked
factors, including team attributes, communication strategies, and checking processes
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psnet.ahrq.gov/node/36072/psn-pdf
July 05, 2006 - taken steps to improve the
reliability of their practitioner licensure and certification screening processes
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psnet.ahrq.gov/node/47306/psn-pdf
March 08, 2019 - on factors
that contribute to preventable maternal mortality, such as omission of recommended care processes
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psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - • Describe optimal fall prevention care processes in long-term care settings.
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - Medication Overdose
Citation Text:
Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
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psnet.ahrq.gov/web-mm/situational-unawareness
August 01, 2009 - Situational (Un)Awareness
Citation Text:
Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/49521/psn-pdf
September 12, 2006 - A Troubling Amine
September 1, 2006
Flynn EA. A Troubling Amine. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/troubling-amine
The Case
A 43-year-old woman was admitted to the intensive care unit for symptoms of heart and respiratory failure.
She was found to have severe mitral and tricuspid valve regurgi…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
September 01, 2006 - Spotlight Case September 2006
Spotlight Case September 2006
Triple Handoff
Source and Credits
This presentation is based on the September 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Arpana Vidyarthi, MD, UCSF Sc…
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psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - Patient Mix-Up
Citation Text:
Shojania KG. Patient Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/node/845360/psn-pdf
March 29, 2023 - Demonstrating the value of a standardized cognitive
assessment tool through the use of interprofessional
rapid safety rounds.
March 29, 2023
Hayes M, Wheeling D, Kaul-Connolly S. Demonstrating the value of a standardized cognitive assessment
tool through the use of interprofessional rapid safety rounds. J Nurs Car…
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psnet.ahrq.gov/node/43928/psn-pdf
April 08, 2018 - Missed diagnoses of acute myocardial infarction in the
emergency department: variation by patient and facility
characteristics.
April 8, 2018
Moy E, Barrett M, Coffey R, et al. Missed diagnoses of acute myocardial infarction in the emergency
department: variation by patient and facility characteristics. Diagnosis …
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psnet.ahrq.gov/node/41451/psn-pdf
October 19, 2012 - Challenges of making a diagnosis in the outpatient
setting: a multi-site survey of primary care physicians.
October 19, 2012
Sarkar U, Bonacum D, Strull W, et al. Challenges of making a diagnosis in the outpatient setting: a multi-
site survey of primary care physicians. BMJ Qual Saf. 2012;21(8):641-648. doi:10.113…
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psnet.ahrq.gov/node/41187/psn-pdf
October 16, 2012 - A pharmacist-led information technology intervention for
medication errors (PINCER): a multicentre, cluster
randomised, controlled trial and cost-effectiveness
analysis.
October 16, 2012
Avery A, Rodgers S, Cantrill JA, et al. A pharmacist-led information technology intervention for medication
errors (PINCER): a …
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psnet.ahrq.gov/node/39526/psn-pdf
December 02, 2014 - Decrease in hospital-wide mortality rate after
implementation of a commercially sold computerized
physician order entry system.
December 2, 2014
Longhurst CA, Parast L, Sandborg CI, et al. Decrease in hospital-wide mortality rate after implementation
of a commercially sold computerized physician order entry system…
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psnet.ahrq.gov/node/38761/psn-pdf
July 15, 2009 - Effect of bar-code–assisted medication administration on
medication administration errors and accuracy in multiple
patient care areas.
July 15, 2009
Helmons PJ, Wargel LN, Daniels CE. Effect of bar-code-assisted medication administration on medication
administration errors and accuracy in multiple patient care are…
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psnet.ahrq.gov/node/47948/psn-pdf
May 29, 2019 - Potential consequences of patient complications for
surgeon well-being: a systematic review.
May 29, 2019
Srinivasa S, Gurney J, Koea J. Potential Consequences of Patient Complications for Surgeon Well-being:
A Systematic Review. JAMA Surg. 2019;154(5):451-457. doi:10.1001/jamasurg.2018.5640.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/44976/psn-pdf
February 14, 2017 - Do patients' disruptive behaviours influence the accuracy
of a doctor's diagnosis? A randomised experiment.
February 14, 2017
Schmidt HG, Van Gog T, Schuit SC, et al. Do patients' disruptive behaviours influence the accuracy of a
doctor's diagnosis? A randomised experiment. BMJ Qual Saf. 2017;26(1):19-23. doi:10.11…
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psnet.ahrq.gov/node/73097/psn-pdf
March 31, 2011 - examines the potential of the profession as arbiters and leaders of efforts to redesign healthcare
processes
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psnet.ahrq.gov/node/41934/psn-pdf
May 24, 2016 - https://psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance