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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
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psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - Amphotericin Toxicity
October 1, 2015
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/amphotericin-toxicity
The Case
A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral
posaconazole for residual fungal disease. She present…
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psnet.ahrq.gov/node/49827/psn-pdf
April 01, 2018 - Walking Patient, Missing Drain
April 1, 2018
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/walking-patient-missing-drain
The Case
A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective
…
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psnet.ahrq.gov/node/72624/psn-pdf
January 05, 2021 - The LifePoint National Quality Program Provides
Structured Framework for Reducing Inpatient Harm
January 5, 2021
https://psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-
reducing-inpatient-harm
Summary
Building on the company’s experience as a Hospital Engagement Network…
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psnet.ahrq.gov/node/49559/psn-pdf
April 01, 2008 - The Forgotten Drip
April 1, 2008
Josephson AS. The Forgotten Drip. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/forgotten-drip
The Case
A 45-year-old man was brought to the emergency department by his friends because of a 1-day history of a
severe headache and "bizarre behavior." A computed tomography (C…
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psnet.ahrq.gov/node/43979/psn-pdf
April 29, 2015 - The Report of the Morecambe Bay Investigation.
April 29, 2015
Kirkup B. London, UK: The Stationery Office; 2015. ISBN: 9780108561306.
https://psnet.ahrq.gov/issue/report-morecambe-bay-investigation
Sharing information about large-scale investigations into failures can provide insights on factors that
contribute to…
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psnet.ahrq.gov/node/46836/psn-pdf
February 21, 2018 - Drone delivery of medications: review of the landscape
and legal considerations.
February 21, 2018
Lin CA, Shah K, Mauntel LCC, et al. Drone delivery of medications: Review of the landscape and legal
considerations. Am J Health Syst Pharm. 2018;75(3):153-158. doi:10.2146/ajhp170196.
https://psnet.ahrq.gov/issue/dr…
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psnet.ahrq.gov/node/46817/psn-pdf
October 13, 2018 - Diagnosing crime and diagnosing disease—part 1 and
part 2.
October 13, 2018
Lockhart JJ, Satya-Murti S. Diagnosing Crime and Diagnosing Disease: Bias Reduction Strategies in the
Forensic and Clinical Sciences. J Forensic Sci. 2017;62(6):1534-1541. doi:10.1111/1556-4029.13453.
https://psnet.ahrq.gov/issue/diagnosin…
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psnet.ahrq.gov/node/45382/psn-pdf
January 23, 2017 - The impact of major intraoperative adverse events on
hospital readmissions.
January 23, 2017
Nandan AR, Bohnen JD, Chang DC, et al. The impact of major intraoperative adverse events on hospital
readmissions. Am J Surg. 2017;213(1):10-17. doi:10.1016/j.amjsurg.2016.03.018.
https://psnet.ahrq.gov/issue/impact-major-…
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psnet.ahrq.gov/node/41434/psn-pdf
June 06, 2012 - ASHP national survey of pharmacy practice in hospital
settings: prescribing and transcribing—2010.
June 6, 2012
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital
settings: prescribing and transcribing--2010. Am J Health Syst Pharm. 2011;68(8):669-88.
doi:10.2146/ajhp…
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psnet.ahrq.gov/node/74219/psn-pdf
January 01, 2022 - Race as a social construct in psychiatry research and
practice.
December 22, 2021
Bryant BE, Jordan A, Clark US. Race as a social construct in psychiatry research and practice. JAMA
Psych. 2022;79(2):93-94. doi:10.1001/jamapsychiatry.2021.2877.
https://psnet.ahrq.gov/issue/race-social-construct-psychiatry-research…
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psnet.ahrq.gov/node/45785/psn-pdf
September 29, 2017 - Traditions of research into interruptions in healthcare: a
conceptual review.
September 29, 2017
McCurdie T, Sanderson P, Aitken LM. Traditions of research into interruptions in healthcare: A conceptual
review. Int J Nurs Stud. 2017;66:23-36. doi:10.1016/j.ijnurstu.2016.11.005.
https://psnet.ahrq.gov/issue/traditi…
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psnet.ahrq.gov/node/72552/psn-pdf
December 09, 2020 - Hospital-acquired SARS-CoV-2 infection: lessons for
public health.
December 9, 2020
Richterman A, Meyerowitz EA, Cevik M. Hospital-acquired SARS-CoV-2 infection: lessons for public
health. JAMA. 2020;324(21):2155. doi:10.1001/jama.2020.21399.
https://psnet.ahrq.gov/issue/hospital-acquired-sars-cov-2-infection-less…
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psnet.ahrq.gov/node/50557/psn-pdf
October 16, 2019 - Effect of an Electronic Medication Reconciliation
Intervention on Adverse Drug Events: A Cluster
Randomized Trial
October 16, 2019
Tamblyn R, Abrahamowicz M, Buckeridge DL, et al. Effect of an Electronic Medication Reconciliation
Intervention on Adverse Drug Events: A Cluster Randomized Trial. JAMA Netw Open. 2019…
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psnet.ahrq.gov/node/45281/psn-pdf
September 01, 2016 - Screen flashes and pop-up reminders: 'alert fatigue'
spreads through medicine.
September 1, 2016
Luthra S. Kaiser Health News. June 15, 2016.
https://psnet.ahrq.gov/issue/screen-flashes-and-pop-reminders-alert-fatigue-spreads-through-medicine
Alert fatigue is known to contribute to medical error. This news article…
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psnet.ahrq.gov/node/60768/psn-pdf
August 05, 2020 - Missed and delayed diagnoses of non-COVID conditions--
collateral harm from a pandemic.
August 5, 2020
Carr S. Missed and delayed diagnoses of non-COVID conditions- collateral harm from a pandemic.
ImproveDx. 2020;7(4):1-5.
https://psnet.ahrq.gov/issue/missed-and-delayed-diagnoses-non-covid-conditions-collateral-h…
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psnet.ahrq.gov/node/44160/psn-pdf
November 06, 2015 - Development of an "infusion pump safety score".
November 6, 2015
Carlson R, Johnson B, Ensign RH. Development of an "infusion pump safety score". Am J Health Syst
Pharm. 2015;72(10):777-9. doi:10.2146/ajhp140421.
https://psnet.ahrq.gov/issue/development-infusion-pump-safety-score
Although infusion pumps improve th…
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psnet.ahrq.gov/node/48091/psn-pdf
June 26, 2019 - Deprescribing Guidelines: Special Section on Symposium
Results.
June 26, 2019
Res Social Adm Pharm. 2019;15(6):780-810.
https://psnet.ahrq.gov/issue/deprescribing-guidelines-special-section-symposium-results
Appropriate deprescribing can reduce the risks associated with polypharmacy, overuse, and accidental
overd…
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psnet.ahrq.gov/node/60363/psn-pdf
March 01, 2021 - Transition Coaches® Reduce Readmissions for Medicare
Patients With Complex Postdischarge Needs
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-
postdischarge-needs
Summary
Under a program kn…
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psnet.ahrq.gov/node/60915/psn-pdf
September 16, 2020 - Deprescribing for community-dwelling older adults: a
systematic review and meta-analysis.
September 16, 2020
Bloomfield HE, Greer N, Linsky AM, et al. Deprescribing for community-dwelling older adults: a systematic
review and meta-analysis. J Gen Intern Med. 2020;35(11):3323-3332. doi:10.1007/s11606-020-06089-2.
h…