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psnet.ahrq.gov/node/837959/psn-pdf
August 31, 2022 - Changes in production processes and substitution of alternative non-latex products (e.g., nitrile
examination
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.104_slideshow.ppt
September 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case September 2005
Double Trouble
Source and Credits
This presentation is based on the Sept. 2005
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Jerry H. Gurwitz, MD, University of…
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psnet.ahrq.gov/node/49571/psn-pdf
October 01, 2008 - Coming Up Short
October 1, 2008
Hochberg Z'ev. Coming Up Short. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/coming-short
The Case
A 12-year-old Hispanic female was seen for a well-child check. The child was delivered 2 months
prematurely (likely due to domestic violence) in Puerto Rico. She had an intra…
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psnet.ahrq.gov/node/33568/psn-pdf
June 15, 2024 - Root Cause Analysis
June 15, 2024
Root Cause Analysis. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/root-cause-analysis
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed…
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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
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psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md
January 01, 2009 - In Conversation with…Thomas H. Gallagher, MD
January 1, 2009
Also Read an Essay
Citation Text:
In Conversation with…Thomas H. Gallagher, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
January 01, 2021 - Spotlight
Spotlight
Culture Clash No More:
Integration and Coordination of Disease
Treatment and Palliative Care
Source and Credits
• This presentation is based on the November 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Han…
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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - A Statewide Collaborative to Support Vaginal Birth and Reduce Unnecessary Cesarean Deliveries
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July 8, 2022
Innovation
Contact
…
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psnet.ahrq.gov/node/33726/psn-pdf
March 01, 2012 - Even
beneath processes that are challenged are responsible individuals.
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
February 01, 2013 - Patients and their families are in a position to recognize small variations in hospital processes and
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - Better reporting of discharge processes and outcomes should also help improve care transitions.
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psnet.ahrq.gov/issue/acog-committee-opinion-508-disruptive-behavior
September 04, 2024 - Commentary
ACOG Committee Opinion #508: disruptive behavior.
Citation Text:
ACOG Committee Opinion No. 508: disruptive behavior. Obstet Gynecol. 2011;118(4):970-2. doi:10.1097/AOG.0b013e3182358acc.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNot…
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psnet.ahrq.gov/node/39501/psn-pdf
January 03, 2017 - Harmful medication errors involving unfractionated and
low-molecular-weight heparin in three patient safety
reporting programs.
January 3, 2017
Grissinger MC, Hicks RW, Keroack MA, et al. Harmful medication errors involving unfractionated and low-
molecular-weight heparin in three patient safety reporting programs…
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psnet.ahrq.gov/node/37387/psn-pdf
January 10, 2017 - Impact of CRM-based team training on obstetric
outcomes and clinicians' patient safety attitudes.
January 10, 2017
Pratt SD, Mann S, Salisbury M, et al. John M. Eisenberg Patient Safety and Quality Awards. Impact of
CRM-based training on obstetric outcomes and clinicians' patient safety attitudes. Jt Comm J Qual Pa…
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psnet.ahrq.gov/node/45293/psn-pdf
February 01, 2017 - Patient safety incidents involving sick children in primary
care in England and Wales: a mixed methods analysis.
February 1, 2017
Rees P, Edwards A, Powell C, et al. Patient Safety Incidents Involving Sick Children in Primary Care in
England and Wales: A Mixed Methods Analysis. PLoS Med. 2017;14(1):e1002217.
doi:1…
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psnet.ahrq.gov/node/845356/psn-pdf
March 29, 2023 - A novel approach for engagement in team training in
high-technology surgery: the robotic-assisted surgery
olympics.
March 29, 2023
Cohen TN, Anger JT, Kanji FF, et al. A novel approach for engagement in team training in high-technology
surgery: the robotic-assisted surgery olympics. J Patient Saf. 2022;18(6):570-5…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-15
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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…
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psnet.ahrq.gov/issue/future-patient-and-family-engagement-quality-and-patient-safety
February 24, 2025 - Special or Theme Issue
The Future of Patient and Family Engagement in Quality and Patient Safety.
Citation Text:
The Future of Patient and Family Engagement in Quality and Patient Safety. Front Health Serv. 2024.
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psnet.ahrq.gov/node/865610/psn-pdf
April 24, 2024 - Suicide Prevention in an Emergency Department
Population: ED-SAFE
April 24, 2024
https://psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
Summary
Suicide is the 12th leading cause of death in the United States, and the 3rd leading cause of death for
people ages 15-24.1 More tha…