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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - Falling Through the Crack (in the Bedrails)
May 1, 2016
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
Case Objectives
Review the epidemiology of patient falls and associated injuries in the hospital set…
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - SPOTLIGHT CASE
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
Citation Text:
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
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psnet.ahrq.gov/issue/safe-labeling-practices-minimize-medication-errors-anesthesia-5-case-reports-and-review
March 26, 2014 - Commentary
Safe labeling practices to minimize medication errors in anesthesia: 5 case reports and review of the literature.
Citation Text:
Prakash S, Mullick P, Kumar A, et al. Safe Labeling Practices to Minimize Medication Errors in Anesthesia. A & A Practice. 2017;10(10). doi:10.1213/…
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psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
September 01, 2007 - These reviews allow the educational leaders of the department to see whether residents and staff are
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psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
May 01, 2009 - WW : They do some chart reviews that get the QIOs [Quality Improvement Organizations] involved in examining
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psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - When I started to perform systematic reviews to understand the literature, I began to see evidence in
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psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - For patient mortality, where the most data would be available, a systematic review found that 8-17 reviews
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psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
August 01, 2006 - , the New England Journal of Medicine bounced it so fast, I don't even know if they sent it out for reviews
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psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - , the New England Journal of Medicine bounced it so fast, I don't even know if they sent it out for reviews
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psnet.ahrq.gov/issue/patient-safety-culture-nephrology-nurse-practice-settings-initial-findings
August 10, 2022 - Study
Patient safety culture in nephrology nurse practice settings: initial findings.
Citation Text:
Patient safety culture in nephrology nurse practice settings: initial findings. Ulrich B, Kear T. Nephrol Nurs J. 2014;41:459-476.
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psnet.ahrq.gov/issue/medication-safety-officers-handbook
September 01, 2018 - Book/Report
Medication Safety Officer's Handbook.
Citation Text:
Medication Safety Officer's Handbook. Larson CM, Saine D, eds. Bethesda, MD: American Society of Health-System Pharmacists; 2013. ISBN: 9781585282104.
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psnet.ahrq.gov/issue/health-care-leader-action-guide-reduce-avoidable-readmissions
March 14, 2018 - Book/Report
Health Care Leader Action Guide to Reduce Avoidable Readmissions.
Citation Text:
Health Care Leader Action Guide to Reduce Avoidable Readmissions. Osei-Anto A, Joshi M, Audet AJ, Berman A, Jencks SF. New York, NY: The Commonwealth Fund, The John Hartford Foundation, Healt…
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psnet.ahrq.gov/issue/documenting-day-discussion-ahead-crest-wave-creating-national-agenda-systemic-change-enhanced
April 28, 2021 - Book/Report
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change for Enhanced Clinician Well-Being.
Citation Text:
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change …
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psnet.ahrq.gov/issue/biased-test-kept-thousands-black-people-getting-kidney-transplant
September 02, 2016 - Newspaper/Magazine Article
A biased test kept thousands of Black people from getting a kidney transplant.
Citation Text:
A biased test kept thousands of Black people from getting a kidney transplant. Neergaard L. Associated Press. April 1, 2024.
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psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they-do-and-how-fix-it
November 20, 2019 - Newspaper/Magazine Article
Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it.
Citation Text:
Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Park A. Time Magazine. January 24, 2019.
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psnet.ahrq.gov/issue/patient-harm-general-surgery-prospective-study
November 16, 2022 - Study
Patient harm in general surgery--a prospective study.
Citation Text:
Kaul AK, McCulloch PG. Patient Harm in General Surgery-A Prospective Study. J Patient Saf. 2008;3(1). doi:10.1097/pts.0b013e318030c2ec.
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DOI Google Scholar BibTeX EndNote X3 XM…
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psnet.ahrq.gov/issue/understanding-and-improving-diagnostic-safety-ambulatory-care
August 17, 2022 - Grant Announcement
Understanding and Improving Diagnostic Safety in Ambulatory Care.
Citation Text:
Understanding and Improving Diagnostic Safety in Ambulatory Care. Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.
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psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection-and-event-reporting-1
July 03, 2013 - Press Release/Announcement
Common formats for patient safety data collection and event reporting.
Citation Text:
Common formats for patient safety data collection and event reporting. Federal Register. Rockville, MD: Agency for Healthcare Research and Quality. February 18, 2014;79:9214…
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psnet.ahrq.gov/issue/why-patient-safety-such-tough-nut-crack
May 03, 2023 - Commentary
Why patient safety is such a tough nut to crack.
Citation Text:
Leistikow IP, Kalkman CJ, de Bruijn H. Why patient safety is such a tough nut to crack. BMJ. 2011;342:d3447. doi:10.1136/bmj.d3447.
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psnet.ahrq.gov/issue/day-joy-died
August 20, 2018 - Newspaper/Magazine Article
The day Joy died.
Citation Text:
Brandeland GP. The day Joy died. Medical economics. 2006;83(20):50, 52-3.
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