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psnet.ahrq.gov/node/845640/psn-pdf
March 08, 2023 - Effect of Patient and Family Centered I-PASS on adverse
event rates in hospitalized children with complex chronic
conditions.
March 8, 2023
Kuzma N, Khan A, Rickey L, et al. Effect of Patient and Family Centered I?PASS on adverse event rates in
hospitalized children with complex chronic conditions. J Hosp Med. 202…
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psnet.ahrq.gov/node/865708/psn-pdf
May 01, 2024 - Missed nursing care in surgical care- a hazard to patient
safety: a quantitative study within the inCHARGE
programme.
May 1, 2024
Edfeldt K, Nyholm L, Jangland E, et al. Missed nursing care in surgical care– a hazard to patient safety: a
quantitative study within the inCHARGE programme. BMC Nurs. 2024;23(1):233. d…
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psnet.ahrq.gov/node/72709/psn-pdf
February 03, 2021 - COVID-19 hospital outbreaks: protecting healthcare
workers to protect frail patients. An Italian observational
cohort study.
February 3, 2021
Vimercati L, De Maria L, Quarato M, et al. COVID-19 hospital outbreaks: Protecting healthcare workers to
protect frail patients. An Italian observational cohort study. Int J…
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psnet.ahrq.gov/node/44812/psn-pdf
February 15, 2017 - Combining systems and teamwork approaches to
enhance the effectiveness of safety improvement
interventions in surgery: the Safer Delivery of Surgical
Services (S3) program.
February 15, 2017
McCulloch P, Morgan L, New S, et al. Combining Systems and Teamwork Approaches to Enhance the
Effectiveness of Safety Impro…
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psnet.ahrq.gov/node/45839/psn-pdf
February 07, 2018 - Mortality trends after a voluntary checklist-based surgical
safety collaborative.
February 7, 2018
Haynes AB, Edmondson L, Lipsitz S, et al. Mortality Trends After a Voluntary Checklist-based Surgical
Safety Collaborative. Ann Surg. 2017;266(6):923-929. doi:10.1097/SLA.0000000000002249.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/45109/psn-pdf
May 11, 2016 - Implementation of the surgical safety checklist in South
Carolina hospitals is associated with improvement in
perceived perioperative safety.
May 11, 2016
Molina G, Jiang W, Edmondson L, et al. Implementation of the Surgical Safety Checklist in South Carolina
Hospitals Is Associated with Improvement in Perceived P…
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psnet.ahrq.gov/node/48085/psn-pdf
June 19, 2019 - A decade of preventing harm.
June 19, 2019
Woeltje KF, Olenski LK, Donatelli M, et al. A Decade of Preventing Harm. Jt Comm J Qual Patient Saf.
2019;45(7):480-486. doi:10.1016/j.jcjq.2019.04.007.
https://psnet.ahrq.gov/issue/decade-preventing-harm
Preventable patient safety problems continue to challenge health ca…
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psnet.ahrq.gov/node/36530/psn-pdf
January 07, 2011 - Impact of extended-duration shifts on medical errors,
adverse events, and attentional failures.
January 7, 2011
Barger LK, Ayas N, Cade BE, et al. Impact of extended-duration shifts on medical errors, adverse events,
and attentional failures. PLoS Med. 2006;3(12):e487.
https://psnet.ahrq.gov/issue/impact-extended-…
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psnet.ahrq.gov/node/866686/psn-pdf
September 11, 2024 - Impact of automated alerts on discharge opioid
overprescribing after general surgery.
September 11, 2024
Rizk E, Kaur N, Duong PY, et al. Impact of automated alerts on discharge opioid overprescribing after
general surgery. Am J Health Syst Pharm. 2024;81(24):1288-1296. doi:10.1093/ajhp/zxae185.
https://psnet.ahrq…
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psnet.ahrq.gov/node/46111/psn-pdf
May 17, 2017 - Implementation and adaptation of the Re-Engineered
Discharge (RED) in five California hospitals: a qualitative
research study.
May 17, 2017
Mitchell SE, Weigel GM, Laurens V, et al. Implementation and adaptation of the Re-Engineered Discharge
(RED) in five California hospitals: a qualitative research study. BMC He…
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psnet.ahrq.gov/web-mm/forgotten-drip
April 01, 2014 - The Forgotten Drip
Citation Text:
Josephson AS. The Forgotten Drip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/node/33797/psn-pdf
January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety
Science, Policy, and Practice
January 1, 2016
Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet
[internet]. 2016.
https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…
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psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3
August 1, 2017
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
The Case
A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the
app…
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psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - Lethal Cap
Citation Text:
Schillinger D. Lethal Cap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Do…
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - Statewide Telehealth Program Enhances Access to Care,
Improves Outcomes for High-Risk Pregnancies in Rural
Area
June 12, 2020
https://psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-
high-risk
Summary
Formerly known as the Antenatal and Neonatal Guidelines, Education…
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psnet.ahrq.gov/node/865778/psn-pdf
May 29, 2024 - Navigating Complications: The Unintended Journey of a
Guidewire During Dialysis Catheter Placement
May 29, 2024
Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis
Catheter Placement. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-complications-unint…
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psnet.ahrq.gov/node/49645/psn-pdf
February 01, 2012 - E-prescribing: E for error?
February 1, 2012
Ashton EW. E-prescribing: E for error? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/e-prescribing-e-error
Case Objectives
Define e-prescribing.
Describe ways in which e-prescribing can reduce health care costs.
State how commonly prescription errors occur wit…
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - Antibiotics for URI/Sinusitis—A Simple Decision Gone
Bad
April 1, 2008
Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
Case Objectives
Understand the indications for antibiotic treatment in …
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psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
February 23, 2022 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement
Citation Text:
Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
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psnet.ahrq.gov/node/861880/psn-pdf
January 31, 2024 - Patient and Family Centered I-PASS (Family-Centered
Communication Program to Reduce Medical Errors and
Improve Family Experience and Communication
Processes)
January 31, 2024
https://psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-
program-reduce-medical
Summary
Medica…