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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - SPOTLIGHT CASE
Diagnosing Diagnostic Mistakes
Citation Text:
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Shaha.pdf
May 01, 2004 - of PDAs and
other technologies upon the implementation of a culture of safety have yet to be
fully recognized
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Gallagher1.pdf
January 01, 2004 - While AHRQ recognized this issue
during algorithm development, and chose to include these patients,
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/West.pdf
September 01, 2005 - analyzing recurring decisions
and processes involving multiple people and complex situations and is recognized
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
January 01, 2004 - determined that the NCC MERP outcome severity index and
definition of a medication error were nationally recognized
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
January 01, 2003 - pertaining to the clinical decisionmaking of
nursing and the context in which nurses monitored patients, recognized
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Graham.pdf
April 14, 2004 - also contribute consistency and efficiency to the process.”16
This possible solution has also been recognized
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Lynch_37.pdf
March 21, 2008 - We also recognized that medication management
has a life cycle and could include an “episode” of multiple
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Masica_112.pdf
November 30, 2010 - insufficient number of events to
demonstrate a statistically significant difference between the groups was recognized
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/factraining.html
December 01, 2014 - How do you review the medical record to see if there were risk factors that were not recognized as important
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www.ahrq.gov/research/findings/final-reports/stpra/stpra2.html
April 01, 2018 - An initial list of basic events was created based on the major risk factors recognized in the extant
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module6-presenters-notes.pdf
January 10, 2022 - We all benefit from
knowing that we have done a good job and that our performance has been
recognized
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module6-mutual-support.pptx
January 10, 2022 - We all benefit from knowing that we have done a good job and that our performance has been recognized
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool4.html
March 01, 2025 - are at particular risk of unmanaged mental health difficulties: Individuals whose symptoms are not recognized
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www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu2.html
October 01, 2014 - members understand why they have been selected, and find ways to ensure that their efforts will be recognized
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www.ahrq.gov/sites/default/files/2024-02/parchman-report.pdf
January 01, 2024 - released by the Center for Disease Control
and Prevention, have been disseminated.10 It has long been recognized
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/003-clabsi-prevention-webinar-fg.docx
October 01, 2024 - Slide 15
Central Line Insertion Bundles
SAY:
The most widely recognized best practices associated
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu2.html
October 01, 2014 - members understand why they have been selected, and find ways to ensure that their efforts will be recognized
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-finalreport-update-2021.pdf
January 01, 2021 - While many of these resources have recognized the critical role of primary care in managing care
transitions