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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Spotlight
Spotlight
Prolonged DKA in Pregnancy: A Case of Communication
Breakdown
Source and Credits
• This presentation is based on the August 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarah Marshall, MD and Nina M. …
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psnet.ahrq.gov/node/843151/psn-pdf
February 01, 2023 - Patient Safety Concerns and the LGBTQ+ Population
February 1, 2023
Wesley C, Van CM, Mossburg S. Patient Safety Concerns and the LGBTQ+ Population. PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/patient-safety-concerns-and-lgbtq-population
Challenges to Obtaining Needed Patient-Centered and Safe Health…
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psnet.ahrq.gov/node/49779/psn-pdf
January 01, 2017 - The Empty Bag
December 1, 2016
Vincent C. The Empty Bag. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/empty-bag
The Case
A 90-year-old woman with end-stage dementia was admitted to an acute care hospital for treatment of a
hip fracture after a fall at a nursing home. During the hospitalization, her kidne…
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psnet.ahrq.gov/issue/corridor-care-emergency-department-managing-patient-care-non-clinical-areas-safely-and
May 19, 2021 - Commentary
'Corridor care' in the emergency department: managing patient care in non-clinical areas safely and efficiently.
Citation Text:
Williams C. ‘Corridor care’ in the emergency department: managing patient care in non-clinical areas safely and efficiently. Emerg Nurse. 2023;31(6):…
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psnet.ahrq.gov/issue/point-care-testing-error-sources-and-amplifiers-taxonomy-prevention-strategies-and-detection
January 08, 2016 - Study
Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection monitors.
Citation Text:
Meier FA, Jones BA. Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection monitors. Arch Pathol Lab Med. 2005…
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psnet.ahrq.gov/issue/case-mistaken-identity-staff-input-patient-id-errors
March 27, 2024 - Study
A case of mistaken identity: staff input on patient ID errors.
Citation Text:
Ortiz J, Amatucci C. A case of mistaken identity: staff input on patient ID errors. Nurs Manag. 2009;40(4):37-41. doi:10.1097/01.NUMA.0000349689.98615.6d.
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Format:
DOI Google …
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psnet.ahrq.gov/issue/safe-electronic-health-record-use-requires-comprehensive-monitoring-and-evaluation-framework
May 22, 2015 - Commentary
Safe electronic health record use requires a comprehensive monitoring and evaluation framework.
Citation Text:
Sittig DF, Classen D. Safe electronic health record use requires a comprehensive monitoring and evaluation framework. JAMA. 2010;303(5):450-451. doi:10.1001/jama.20…
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psnet.ahrq.gov/issue/association-between-organisational-and-workplace-cultures-and-patient-outcomes-systematic
February 03, 2011 - Review
Association between organisational and workplace cultures, and patient outcomes: systematic review.
Citation Text:
Braithwaite J, Herkes J, Ludlow K, et al. Association between organisational and workplace cultures, and patient outcomes: systematic review. BMJ Open. 2017;7(11). do…
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psnet.ahrq.gov/issue/behavioral-integrity-safety-priority-safety-psychological-safety-and-patient-safety-team
April 21, 2010 - Study
Behavioral integrity for safety, priority of safety, psychological safety, and patient safety: a team-level study.
Citation Text:
Leroy H, Dierynck B, Anseel F, et al. Behavioral integrity for safety, priority of safety, psychological safety, and patient safety: A team-level study…
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psnet.ahrq.gov/issue/clinical-scenarios-enhancing-skill-set-nurse-vigilant-guardian
July 19, 2023 - Study
Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian.
Citation Text:
Jacobson T, Belcher E, Sarr B, et al. Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian. J Contin Educ Nurs. 2010;41(8):347-53; quiz 354-5. doi:10.3928/0…
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psnet.ahrq.gov/issue/checklists-change-communication-about-key-elements-patient-care
November 16, 2022 - Study
Checklists change communication about key elements of patient care.
Citation Text:
Newkirk M, Pamplin JC, Kuwamoto R, et al. Checklists change communication about key elements of patient care. J Trauma Acute Care Surg. 2012;73(2 Suppl 1):S75-82. doi:10.1097/TA.0b013e3182606239.
…
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psnet.ahrq.gov/issue/accuracy-adverse-drug-event-reports-collected-using-automated-dispensing-system
April 06, 2022 - Study
Accuracy of adverse-drug-event reports collected using an automated dispensing system.
Citation Text:
Romero A, Malone DC. Accuracy of adverse-drug-event reports collected using an automated dispensing system. Am J Health Syst Pharm. 2005;62(13):1375-80.
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Forma…
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psnet.ahrq.gov/issue/guidance-patient-safety-ophthalmology-royal-college-ophthalmologists
November 12, 2014 - Review
Guidance on patient safety in ophthalmology from the Royal College of Ophthalmologists.
Citation Text:
Kelly SP, Ophthalmologists RC of. Guidance on patient safety in ophthalmology from the Royal College of Ophthalmologists. Eye (Lond). 2009;23(12):2143-51. doi:10.1038/eye.2009.…
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psnet.ahrq.gov/issue/validity-retrospective-review-medical-records-means-identifying-adverse-events-comparison
October 25, 2023 - Study
Validity of retrospective review of medical records as a means of identifying adverse events: comparison between medical records and accident reports.
Citation Text:
Kobayashi M, Ikeda S, Kitazawa N, et al. Validity of retrospective review of medical records as a means of identif…
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psnet.ahrq.gov/issue/current-pulse-can-production-system-reduce-medical-errors-health-care
September 09, 2011 - Commentary
Current pulse: can a production system reduce medical errors in health care?
Citation Text:
Printezis A, Gopalakrishnan M. Current pulse: can a production system reduce medical errors in health care? Qual Manag Health Care. 2007;16(3):226-238.
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…
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psnet.ahrq.gov/issue/junior-doctors-and-patient-safety-evaluating-knowledge-attitudes-and-perception-safety
February 18, 2019 - Study
Junior doctors and patient safety: evaluating knowledge, attitudes and perception of safety climate.
Citation Text:
Durani P, Dias J, Singh HP, et al. Junior doctors and patient safety: evaluating knowledge, attitudes and perception of safety climate. BMJ Qual Saf. 2013;22(1):65-…
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psnet.ahrq.gov/issue/promoting-engagement-patients-and-families-reduce-adverse-events-acute-care-settings
July 02, 2014 - Review
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
Citation Text:
Berger ZD, Flickinger TE, Pfoh ER, et al. Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic …
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psnet.ahrq.gov/issue/safe-patients-smart-hospitals-how-one-doctors-checklist-can-help-us-change-health-care-inside
January 27, 2021 - Book/Report
Classic
Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.
Citation Text:
Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. Prono…
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psnet.ahrq.gov/issue/expert-consensus-currently-accepted-measures-harm
January 25, 2023 - Commentary
Expert consensus on currently accepted measures of harm.
Citation Text:
Logan MS, Myers LC, Salmasian H, et al. Expert consensus on currently accepted measures of harm. J Patient Saf. 2021;17(8):e1726-e1731. doi:10.1097/pts.0000000000000754.
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…
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psnet.ahrq.gov/issue/preventing-medication-errors-quality-chasm-series
January 04, 2009 - Book/Report
Classic
Preventing Medication Errors: Quality Chasm Series.
Citation Text:
Preventing Medication Errors: Quality Chasm Series. Aspden P, Wolcott J, Bootman JL, et al, eds; Institute of Medicine, Committee on Identifying and Preventing Medication …