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psnet.ahrq.gov/curated-library/artificial-intelligence-system-level-considerations
March 27, 2024 - Resources specific to distinct tasks (decision support) and care processes (diagnosis) are not included
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - 13 ) Examples of approaches based on systems theory include the systems-theoretic accident model and processes
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
January 01, 2024 - Computed tomography (CT) of the head without contrast was negative for acute intracranial processes,
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - Institution of standardized patient handoff methods, supported by processes that enable clinical information
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psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE
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psnet.ahrq.gov/node/74120/psn-pdf
November 30, 2021 - Culture Clash No More: Integration and Coordination of
Disease Treatment and Palliative Care
November 30, 2021
Spero H, Usher AE, Howard B, et al. Culture Clash No More: Integration and Coordination of Disease
Treatment and Palliative Care . PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/culture-clash-no-mo…
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psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
September 27, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up
Citation Text:
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/issue/patient-safety-incident-response-framework
October 20, 2021 - Toolkit
Patient Safety Incident Response Framework.
Citation Text:
Patient Safety Incident Response Framework. London, England: NHS England; August 2022.
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psnet.ahrq.gov/issue/medication-reconciliation-handbook-2nd-edition
May 04, 2015 - Book/Report
Medication Reconciliation Handbook, 2nd edition.
Citation Text:
Medication Reconciliation Handbook, 2nd edition. American Society of Health-System Pharmacists, Joint Commission on Accreditation of Healthcare Organizations. Oakbrook Terrace IL; Joint Commission Resources: 2009…
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psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-ambulatory-care
December 24, 2008 - Tools/Toolkit
Toolkit To Improve Antibiotic Use in Ambulatory Care.
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Toolkit To Improve Antibiotic Use in Ambulatory Care. Rockville, MD: Agency for Healthcare Research and Quality; October 2022.
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psnet.ahrq.gov/issue/good-bad-and-ugly-patient-experiences-crps
February 28, 2024 - Webinar
The Good, The Bad, and The Ugly: Patient Experiences with CRPs.
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The Good, The Bad, and The Ugly: Patient Experiences with CRPs. Collaborative for Accountability and Improvement. October 21, 2021.
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psnet.ahrq.gov/issue/preventing-wrong-site-surgery-minnesota-5-year-journey
December 19, 2007 - Newspaper/Magazine Article
Preventing wrong-site surgery in Minnesota: a 5-year journey.
Citation Text:
Preventing wrong-site surgery in Minnesota: a 5-year journey. Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34.
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psnet.ahrq.gov/issue/agent-change
September 01, 2021 - Newspaper/Magazine Article
Agent of change.
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Agent of change. Gale SF. Chief Learning Officer. July/August 2018;17:22-25.
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psnet.ahrq.gov/issue/explicit-and-standardized-prescription-medicine-instructions
May 01, 2015 - Fact Sheet/FAQs
Explicit and Standardized Prescription Medicine Instructions.
Citation Text:
Explicit and Standardized Prescription Medicine Instructions. Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
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psnet.ahrq.gov/issue/health-information-technology-and-patient-safety-dynamic-discussion
November 07, 2012 - Book/Report
Health Information Technology and Patient Safety: A Dynamic Discussion.
Citation Text:
Health Information Technology and Patient Safety: A Dynamic Discussion. Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; May 2011.
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psnet.ahrq.gov/issue/care-transitions-know-how-not-just-clinicians
May 09, 2018 - Newspaper/Magazine Article
Care transitions know-how not just for clinicians.
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Care transitions know-how not just for clinicians. Ready T. HealthLeaders Media. September 26, 2017.
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psnet.ahrq.gov/issue/technical-patient-safety-solutions-medicines-reconciliation-admission-adults-hospital
October 27, 2021 - Organizational Policy/Guidelines
Technical patient safety solutions for medicines reconciliation on admission of adults to hospital.
Citation Text:
Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. Manchester, UK: National Institute…
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psnet.ahrq.gov/issue/inside-epidemic-misdiagnosed-women
February 02, 2022 - Newspaper/Magazine Article
Inside the epidemic of misdiagnosed women.
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Inside the epidemic of misdiagnosed women. Rabbitt M. Prevention Magazine. April 9, 2020.
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psnet.ahrq.gov/issue/building-case-medication-reconciliation
June 10, 2018 - Newspaper/Magazine Article
Building a case for medication reconciliation.
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Building a case for medication reconciliation. ISMP Medication Safety Alert! Acute care edition. April 21, 2005.
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psnet.ahrq.gov/issue/investigation-detection-retained-vaginal-swabs-and-tampons-following-childbirth
April 01, 2019 - Book/Report
Investigation into Detection of Retained Vaginal Swabs and Tampons Following Childbirth.
Citation Text:
Investigation into Detection of Retained Vaginal Swabs and Tampons Following Childbirth. Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
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