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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37282/psn-pdf
    September 27, 2016 - Verbal medication orders in the OR. September 27, 2016 Hendrickson T. Verbal medication orders in the OR. AORN J. 2007;86(4):626-9. https://psnet.ahrq.gov/issue/verbal-medication-orders-or This article describes the causes of medication errors in the operating room and discusses prevention strategies, including us…
  2. digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015337-mingle-final-report-2008.pdf
    January 01, 2008 - It also makes sense that more ER visits and reduced access to the primary care doctor leads to a higher
  3. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
    January 01, 2004 - Diagnostic Failure: A Cognitive and Affective Approach 241 Diagnostic Failure: A Cognitive and Affective Approach Pat Croskerry Abstract Diagnosis is the foundation of medicine. Effective treatment cannot begin until an accurate diagnosis has been made. Diagnostic reasoning is a critical aspect of clinic…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37305/psn-pdf
    January 02, 2011 - Medication administration in anesthesia: time for a paradigm shift. January 2, 2011 Stabile M; Webster CS; Merry AF. https://psnet.ahrq.gov/issue/medication-administration-anesthesia-time-paradigm-shift To reduce anesthesia administration errors, the authors propose changing the organizational culture to foster a…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34905/psn-pdf
    February 25, 2009 - On the quest for Six Sigma. February 25, 2009 Moorman D. On the quest for Six Sigma. Am J Surg. 2005;189(3):253-8. https://psnet.ahrq.gov/issue/quest-six-sigma This discussion of patient safety from a surgical perspective highlights issues involving hierarchy, human factors, and multidisciplinary team training as …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40497/psn-pdf
    June 15, 2011 - Are we finally getting serious about medical errors? June 15, 2011 Burns J. https://psnet.ahrq.gov/issue/are-we-finally-getting-serious-about-medical-errors This article explores the challenges to improving patient safety and discusses strategies for reducing medical errors. https://psnet.ahrq.gov/issue/are-we-fi…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40299/psn-pdf
    April 16, 2018 - Medication errors in the emergency department: need for pharmacy involvement? April 16, 2018 https://psnet.ahrq.gov/issue/medication-errors-emergency-department-need-pharmacy-involvement This piece reports on the prevalence of medication errors in the emergency department and suggests expanding pharmacy involvemen…
  8. www.ahrq.gov/nursing-home/resources/ventilation-covid-19.html
    May 01, 2022 - Ventilation (COVID-19) Resource: Ventilation (COVID-19) This page provides an updated version of the Centers for Disease Control and Prevention's recommended strategies for using ventilation to reduce exposures to COVID-19, and features ventilation improvement tools and FAQs. Source: CDC Topic(s): Inf…
  9. www.ahrq.gov/hai/cusp/videos/03a-engage-senior-exec/index.html
    June 01, 2018 - Engage the Senior Executive CUSP Toolkit The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit. Engage the Seni…
  10. www.ahrq.gov/antibiotic-use/acute-care/safety/changes.html
    November 01, 2019 - Making Effective Changes in Antibiotic Decision Making After viewing or presenting this presentation viewers will be able to— Identify relevant factors that could improve antibiotic use  Identify interventions to reduce future harm associated with unnecessary antibiotic use Apply interventions to effe…
  11. www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/ps-research-summary-pfe.pdf
    April 30, 2025 - PARS) promoted professional self-governance, fostered a fair and just culture of patient safety, and reduced … A study of the decision aids reduced the use of discretionary surgery without apparent adverse effects
  12. psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
    March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety Sara J. Singer, MBA, PhD | September 1, 2013  View more articles from the same authors. Citation Text: Singer SJ. What We've Learned About Leveraging Leadership a…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49812/psn-pdf
    November 01, 2017 - Specimen Almost Lost November 1, 2017 Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/specimen-almost-lost The Case A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen. She was admitted to the medicine service for further evalu…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49532/psn-pdf
    March 15, 2007 - Back to Basics March 1, 2007 Hellman R. Back to Basics. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/back-basics The Case A 48-year-old woman with insulin-dependent diabetes mellitus presents to the emergency department with right upper quadrant pain, fever, and leukocytosis, prompting admission for pres…
  15. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
    April 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case April 2008 Antibiotics for URI/Sinusitis: A Simple Decision Gone Bad Source and Credits This presentation is based on the April 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Sumant Ranji, MD,…
  16. psnet.ahrq.gov/innovation/critical-radiology-alert-process
    November 16, 2022 - Critical Radiology Alert Process Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL October 30, 2024 View more articles from the same authors. Innovation Contact …
  17. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
    November 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case November 2006 Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Source and Credits This presentation is based on the November 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is…
  18. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
    June 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case June 2005 Getting to the Root of the Matter Source and Credits This presentation is based on the June 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: Scott Flanders, MD; Sa…
  19. www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-refs.html
    September 01, 2013 - Universal ICU Decolonization: An Enhanced Protocol References Previous Page Next Page Table of Contents Universal ICU Decolonization: An Enhanced Protocol Introduction and Welcome Universal ICU Decolonization Protocol Overview Scientific Rationale References Appendix A. Flow Chart for Impl…
  20. www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-refs.html
    September 01, 2013 - Universal ICU Decolonization: An Enhanced Protocol References Previous Page Next Page Table of Contents Universal ICU Decolonization: An Enhanced Protocol Introduction and Welcome Universal ICU Decolonization Protocol Overview Scientific Rationale References Appendix A. Flow Chart for Impl…