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psnet.ahrq.gov/node/42325/psn-pdf
March 02, 2023 - Hospital discharge and readmission.
March 2, 2023
Alper E, O'Malley TA, Greenwald J. UpToDate. February 3, 2023.
https://psnet.ahrq.gov/issue/hospital-discharge-and-readmission
This review examines hospital discharge, details elements of the process that can increase risk of
readmission, and reveals interventions …
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psnet.ahrq.gov/node/41111/psn-pdf
May 21, 2014 - Are they safe in there? Patient safety and trainees in the
practice.
May 21, 2014
Byrnes PD, Crawford M, Wong B. Are they safe in there? - patient safety and trainees in the practice. Aust
Fam Physician. 2012;41(1-2):26-9.
https://psnet.ahrq.gov/issue/are-they-safe-there-patient-safety-and-trainees-practice
This …
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psnet.ahrq.gov/node/40704/psn-pdf
August 17, 2011 - Plan for quality to improve patient safety at the point of
care.
August 17, 2011
Ehrmeyer SS. Plan for Quality to Improve Patient Safety at the Point of Care. Ann Saudi Med. 2011;31(4).
doi:10.4103/0256-4947.83203.
https://psnet.ahrq.gov/issue/plan-quality-improve-patient-safety-point-care
This review discusses t…
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psnet.ahrq.gov/node/35517/psn-pdf
November 17, 2016 - Joint Commission Journal on Quality and Patient Safety.
November 17, 2016
Baker D, ed. Oakbrook Terrace, IL: Joint Commission. ISSN: 1553-7250.
https://psnet.ahrq.gov/issue/joint-commission-journal-quality-and-patient-safety
This monthly, peer-reviewed journal provides both empirical studies and practical instructi…
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psnet.ahrq.gov/node/33903/psn-pdf
November 28, 2018 - ECRI Guidelines Trust.
November 28, 2018
ECRI Institute.
https://psnet.ahrq.gov/issue/ecri-guidelines-trust
This website is a practical resource to review existing clinical practice guidelines in a centralized location.
Key components of the site include links to full-text guidelines and an assessment function tha…
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psnet.ahrq.gov/node/41278/psn-pdf
April 04, 2012 - Strategies to reduce medication errors in pediatric
ambulatory settings.
April 4, 2012
Mehndiratta S. Strategies to reduce medication errors in pediatric ambulatory settings. J Postgrad Med.
2012;58(1):47-53. doi:10.4103/0022-3859.93252.
https://psnet.ahrq.gov/issue/strategies-reduce-medication-errors-pediatric-am…
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psnet.ahrq.gov/node/41039/psn-pdf
January 04, 2012 - There's a science for that: team development
interventions in organizations.
January 4, 2012
Shuffler ML, DiazGranados D, Salas E. There’s a Science for That. Curr Dir Psychol Sci. 2011;20(6).
doi:10.1177/0963721411422054.
https://psnet.ahrq.gov/issue/theres-science-team-development-interventions-organizations
Th…
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psnet.ahrq.gov/node/38066/psn-pdf
September 17, 2008 - New perspectives on error in critical care.
September 17, 2008
Patel VL, Cohen T. New perspectives on error in critical care. Curr Opin Crit Care. 2008;14(4):456-9.
doi:10.1097/MCC.0b013e32830634ae.
https://psnet.ahrq.gov/issue/new-perspectives-error-critical-care
This review article describes approaches to safety…
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psnet.ahrq.gov/node/42217/psn-pdf
December 18, 2013 - A concept analysis of situational awareness in nursing.
December 18, 2013
Fore AM, Sculli GL. A concept analysis of situational awareness in nursing. J Adv Nurs. 2013;69(12):2613-
21. doi:10.1111/jan.12130.
https://psnet.ahrq.gov/issue/concept-analysis-situational-awareness-nursing
This review examines situational…
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psnet.ahrq.gov/node/42108/psn-pdf
March 13, 2013 - Distractions and their impact on patient safety.
March 13, 2013
Feil M. PA-PSRS Patient Saf Advis. March 2013;10:1-10.
https://psnet.ahrq.gov/issue/distractions-and-their-impact-patient-safety
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece outlines the
types of distraction…
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psnet.ahrq.gov/node/35160/psn-pdf
January 02, 2017 - Unlabeled containers lead to patient's death.
January 2, 2017
Cohen MR, Smetzer JL. Unlabeled containers lead to patient's death. Jt Comm J Qual Patient Saf.
2005;31(7):414-7.
https://psnet.ahrq.gov/issue/unlabeled-containers-lead-patients-death
The authors review selected incidents of harm involving unlabeled con…
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psnet.ahrq.gov/node/42707/psn-pdf
September 03, 2024 - Quality Institute Toolkits.
September 3, 2024
AAAHC Quality Institute. Deerfield, IL: Accreditation Association for Ambulatory Health Care.
https://psnet.ahrq.gov/issue/quality-institute-toolkits
This collection of toolkits provides resources to support safety in ambulatory care and includes information
about alle…
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only
Spotlight
Delay in Appropriate Diagnosis and
Treatment Leading to Death from
Pulmonary Embolism
Source and Credits
• This presentation is based on the February 2021 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - SPOTLIGHT CASE
Premature Closure: Was It Just Syncope?
Citation Text:
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Format:
…
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psnet.ahrq.gov/node/60066/psn-pdf
March 25, 2020 - Some Patients Can't Wait: Improving Timeliness of
Emergency Department Care
March 25, 2020
Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
D…
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psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
January 29, 2021 - SPOTLIGHT CASE
Intraoperative Awareness during Rhinoplasty
Citation Text:
Bohringer C, Toor J. Intraoperative Awareness during Rhinoplasty. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/issue/implementation-patient-safety-program-tertiary-health-system-longitudinal-analysis
November 29, 2023 - Study
Implementation of a patient safety program at a tertiary health system: a longitudinal analysis of interventions and serious safety events.
Citation Text:
Cropper DP, Harb NH, Said PA, et al. Implementation of a patient safety program at a tertiary health system: A longitudinal ana…
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psnet.ahrq.gov/issue/addressing-health-care-needs-people-who-identify-transgender-what-do-nurses-need-know
February 17, 2021 - Commentary
Addressing the health care needs of people who identify as transgender: what do nurses need to know?
Citation Text:
Boucher I, Bourke SL, Green J, et al. Addressing the health care needs of people who identify as transgender: what do nurses need to know? Int J Healthc. 2020;6(…
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psnet.ahrq.gov/issue/safe-electronic-health-record-use-requires-comprehensive-monitoring-and-evaluation-framework
May 22, 2015 - Commentary
Safe electronic health record use requires a comprehensive monitoring and evaluation framework.
Citation Text:
Sittig DF, Classen D. Safe electronic health record use requires a comprehensive monitoring and evaluation framework. JAMA. 2010;303(5):450-451. doi:10.1001/jama.20…
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psnet.ahrq.gov/issue/abdominal-pain-emergency-department-missed-diagnoses
September 16, 2020 - Commentary
Abdominal pain in the emergency department: missed diagnoses.
Citation Text:
Halsey-Nichols M, McCoin N. Abdominal pain in the emergency department: missed diagnoses. Emerg Med Clin North Am. 2021;39(4):703-717. doi:10.1016/j.emc.2021.07.005.
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