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psnet.ahrq.gov/node/35382/psn-pdf
October 05, 2005 - Rx for a better prescription. Hospital bans doctors from
using confusing medical abbreviations.
October 5, 2005
Hall J. Fredericksburg Times. September 25, 2005
https://psnet.ahrq.gov/issue/rx-better-prescription-hospital-bans-doctors-using-confusing-medical-
abbreviations
This article presents one hospital’s pro…
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psnet.ahrq.gov/node/42344/psn-pdf
September 24, 2016 - Strategies for preventing distractions and interruptions in
the OR.
September 24, 2016
Clark GJ. Strategies for preventing distractions and interruptions in the OR. AORN J. 2013;97(6):702-707.
doi:10.1016/j.aorn.2013.01.018.
https://psnet.ahrq.gov/issue/strategies-preventing-distractions-and-interruptions-or
Dist…
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psnet.ahrq.gov/node/42332/psn-pdf
June 12, 2013 - Quality improvement through implementation of
discharge order reconciliation.
June 12, 2013
Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order
reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050.
https://psnet.ahrq.gov/issue/quality-impr…
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psnet.ahrq.gov/node/40903/psn-pdf
March 08, 2015 - Does your patient really understand?
March 8, 2015
Huff C. Does your patient really understand? Hospitals & health networks. 2011;85(10):34-5, 37-8, 2.
https://psnet.ahrq.gov/issue/does-your-patient-really-understand
This article discusses health literacy and describes an initiative to reduce gaps in understanding …
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psnet.ahrq.gov/node/42753/psn-pdf
November 20, 2013 - Dealing with a medical mistake: should physicians
apologize to patients?
November 20, 2013
Tabler NG Jr.
https://psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients
This article discusses how apologies address patients' needs when a medical mistake has occurred and
how such disclosur…
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psnet.ahrq.gov/node/37704/psn-pdf
April 23, 2008 - Decreasing paediatric prescribing errors in a district
general hospital.
April 23, 2008
Davey AL, Britland A, Naylor RJ. Decreasing paediatric prescribing errors in a district general hospital.
Qual Saf Health Care. 2008;17(2):146-9. doi:10.1136/qshc.2006.021212.
https://psnet.ahrq.gov/issue/decreasing-paediatric-…
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psnet.ahrq.gov/print/pdf/node/867461
January 31, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Patient and Family Engagement in Long
Term Care
Curated Library
Foundations
Long-term Care and Patient Safety
Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA | April, 10 2024
A large and growing number of Americans require care in skilled nursin…
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
Save
Save to your library
Print
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…
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psnet.ahrq.gov/primer/burnout
November 20, 2024 - Burnout
Citation Text:
Yellowlees P, Rea M. Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Do…
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psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities
Citation Text:
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…
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psnet.ahrq.gov/web-mm/breakage-picc-line
June 21, 2023 - SPOTLIGHT CASE
Breakage of a PICC Line
Citation Text:
Dimov V. Breakage of a PICC Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - The Inside of a Time Out
Citation Text:
Feldman DL. The Inside of a Time Out. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
January 01, 2024 - Spotlight
Spotlight
A Fatal Twist in Pseudohyperkalemia
1
Source and Credits
This presentation is based on the August 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Le…
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Medication Mix-Up: From Bad to Worse
Citation Text:
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - SNFs: Opening the Black Box
December 1, 2013
Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/snfs-opening-black-box
The Case
An 88-year-old woman was admitted to a skilled nursing facility (SNF) after a lengthy hospitalization for a
small bowel obstructio…
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psnet.ahrq.gov/web-mm/transition-nowhere
March 21, 2009 - Transition to Nowhere
Citation Text:
Farrell TW. Transition to Nowhere. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/troubling-amine
September 01, 2003 - A Troubling Amine
Citation Text:
Flynn EA. A Troubling Amine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap
Citation Text:
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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