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psnet.ahrq.gov/node/47252/psn-pdf
August 01, 2018 - Communication errors in radiology—pitfalls and how to
avoid them.
August 1, 2018
Waite S, Scott JM, Drexler I, et al. Communication errors in radiology - Pitfalls and how to avoid them. Clin
Imaging. 2018;51:266-272. doi:10.1016/j.clinimag.2018.05.025.
https://psnet.ahrq.gov/issue/communication-errors-radiology-pi…
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psnet.ahrq.gov/node/43361/psn-pdf
July 16, 2014 - An Avoidable Death of a Three-year-old Child from
Sepsis.
July 16, 2014
London, UK: Parliamentary and Health Service Ombudsman; June 2014.
https://psnet.ahrq.gov/issue/avoidable-death-three-year-old-child-sepsis
This investigation outlines how inadequate care contributed to the death of a child who developed sepsi…
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psnet.ahrq.gov/node/45592/psn-pdf
October 27, 2016 - Preventing Patient Falls: A Systematic Approach From
the Joint Commission Center for Transforming Healthcare
Project.
October 27, 2016
Chicago, IL: Health Research & Educational Trust; October 2016.
https://psnet.ahrq.gov/issue/preventing-patient-falls-systematic-approach-joint-commission-center-
transforming-hea…
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psnet.ahrq.gov/node/855100/psn-pdf
November 08, 2023 - Prescription for disaster: America's broken pharmacy
system in revolt over burnout and errors.
November 8, 2023
Le Coz E. USA Today. October 26, 2023.
https://psnet.ahrq.gov/issue/prescription-disaster-americas-broken-pharmacy-system-revolt-over-burnout-
and-errors
Chain pharmacies provide prescriptions in an env…
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psnet.ahrq.gov/node/39504/psn-pdf
May 05, 2010 - Patient whiteboards as a communication tool in the
hospital setting: A survey of practices and
recommendations.
May 5, 2010
Sehgal NL, Green A, Vidyarthi A, et al. Patient whiteboards as a communication tool in the hospital setting:
a survey of practices and recommendations. J Hosp Med. 2010;5(4):234-9. doi:10.100…
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psnet.ahrq.gov/node/48149/psn-pdf
July 31, 2019 - Zero Harm: How to Achieve Patient and Workforce Safety
in Healthcare.
July 31, 2019
Clapper C, Merlino J, Stockmeier C, eds. New York, NY: McGraw-Hill Education; 2019. ISBN:
9781260440928.
https://psnet.ahrq.gov/issue/zero-harm-how-achieve-patient-and-workforce-safety-healthcare
Achieving zero preventable harms h…
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psnet.ahrq.gov/node/60007/psn-pdf
March 04, 2020 - ISMP Guidelines for Optimizing Safe Implementation and
Use of Smart Infusion Pumps.
March 4, 2020
Horsham, PA: Institute for Safe Medication Practices; 2020.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-implementation-and-use-smart-infusion-
pumps
Smart pumps are widely available as a medicat…
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psnet.ahrq.gov/node/45001/psn-pdf
June 01, 2016 - Relationship between job burnout, psychosocial factors
and health care–associated infections in critical care
units.
June 1, 2016
Galletta M, Portoghese I, D'Aloja E, et al. Relationship between job burnout, psychosocial factors and
health care-associated infections in critical care units. Intensive Crit Care Nurs…
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psnet.ahrq.gov/node/43024/psn-pdf
March 05, 2014 - Speaking up for patient safety by hospital-based health
care professionals: a literature review.
March 5, 2014
Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care
professionals: a literature review. BMC Health Serv Res. 2014;14:61. doi:10.1186/1472-6963-14-61.
https://psnet.…
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psnet.ahrq.gov/node/47956/psn-pdf
June 26, 2019 - Family involvement in managing medications of older
patients across transitions of care: a systematic review.
June 26, 2019
Manias E, Bucknall T, Hughes C, et al. Family involvement in managing medications of older patients
across transitions of care: a systematic review. BMC Geriatr. 2019;19(1):95. doi:10.1186/s12…
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psnet.ahrq.gov/node/43058/psn-pdf
March 26, 2014 - A strategic approach to quality improvement and patient
safety education and resident integration in a general
surgery residency.
March 26, 2014
O'Heron CT, Jarman BT. A strategic approach to quality improvement and patient safety education and
resident integration in a general surgery residency. J Surg Educ. 2014…
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psnet.ahrq.gov/node/72606/psn-pdf
December 23, 2020 - Best Practices in Developing Proprietary Names for
Human Prescription Drug Products Guidance for Industry.
December 23, 2020
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for
Drug Evaluation and Research; December 2020.
https://psnet.ahrq.gov/issue/best-practices-d…
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psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - SPOTLIGHT CASE
Monitoring Fetal Health
Citation Text:
Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNot…
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psnet.ahrq.gov/node/49537/psn-pdf
June 01, 2007 - Beeline to Spine
June 1, 2007
Smetana GW. Beeline to Spine. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/beeline-spine
Case Objectives
Understand the elements of preoperative medical evaluation.
Appreciate the limited role for preoperative laboratory testing.
Appreciate the importance of communication a…
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psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon
Citation Text:
Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/node/45579/psn-pdf
November 01, 2017 - Factors influencing patient safety during postoperative
handover.
November 1, 2017
Rose M, Newman SD. AANA J. 2016;84:329-338.
https://psnet.ahrq.gov/issue/factors-influencing-patient-safety-during-postoperative-handover
Patient handoffs between care teams are vulnerable to error. This scoping review explored the …
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psnet.ahrq.gov/node/60256/psn-pdf
April 22, 2020 - A critical review: moral injury in nurses in the aftermath of
a patient safety incident.
April 22, 2020
Stovall M, Hansen L, van Ryn M. A critical review: moral injury in nurses in the aftermath of a patient safety
incident. J Nurs Scholarsh. 2020;52(3):320-328. doi:10.1111/jnu.12551.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/853435/psn-pdf
September 13, 2023 - Assessing the utility of ChatGPT throughout the entire
clinical workflow: development and usability study.
September 13, 2023
Rao A, Pang M, Kim J, et al. Assessing the utility of ChatGPT throughout the entire clinical workflow:
development and usability study. J Med Internet Res. 2023;25:e48659. doi:10.2196/48659.…
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psnet.ahrq.gov/node/43792/psn-pdf
January 07, 2015 - Patient safety risks associated with telecare: a systematic
review and narrative synthesis of the literature.
January 7, 2015
Guise V, Anderson JE, Wiig S. Patient safety risks associated with telecare: a systematic review and
narrative synthesis of the literature. BMC Health Serv Res. 2014;14:588. doi:10.1186/s129…
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psnet.ahrq.gov/node/46314/psn-pdf
November 01, 2020 - AHRQ Safety Program for Improving Antibiotic Use.
July 9, 2019
Agency for Healthcare Research and Quality, Johns Hopkins Medicine Armstrong Institute for Patient
Safety and Quality, and University of Chicago.
https://psnet.ahrq.gov/issue/ahrq-safety-program-improving-antibiotic-use
Improving antibiotic use is a st…