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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - application: Before rolling out the system, make sure all staff practice using it through simulated scenarios
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/lp-or-not-lp
February 01, 2018 - To LP or Not LP
Citation Text:
Landrigan CP. To LP or Not LP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/49850/psn-pdf
January 01, 2019 - Reported examples include order sets designed for relatively simple scenarios such as
standardizing
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psnet.ahrq.gov/web-mm/bleeding-risk
November 01, 2003 - Bleeding Risk
Citation Text:
Crowther MA. Bleeding Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - The Dropped Lung
Citation Text:
Heffner JR. The Dropped Lung. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
August 01, 2014 - PowerPoint Presentation
Spotlight
Pitfalls in Diagnosing Necrotizing Fasciitis
This presentation is based on the July/August 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Terence Goh, MBBS, Department of Plastic Surgery, Singapore General Hos…
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - A Mistaken Dose of Naloxone?
December 18, 2019
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
The Case
A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up
appointment. He h…
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psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
January 01, 2019 - Spotlight
Spotlight
"Do You Want Everything Done?":
Clarifying Code Status
Source and Credits
• This presentation is based on the December 2019
AHRQ WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Karl Steinberg MD, CMD, HMDC & Thaddeus
M…
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psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - The Case for Patient Flow Management
November 1, 2011
Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/case-patient-flow-management
The Case
A 52-year-old woman with a history of major depression, posttraumatic stress disorder, and alcohol abuse
wa…
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psnet.ahrq.gov/node/73901/psn-pdf
September 29, 2021 - Handshake antimicrobial stewardship as a model to
recognize and prevent diagnostic errors
September 29, 2021
Searns JB, Williams MC, MacBrayne CE, et al. Handshake antimicrobial stewardship as a model to
recognize and prevent diagnostic errors. Diagnosis (Berl). 2020;8(3):347-352. doi:10.1515/dx-2020-0032.
https:/…
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psnet.ahrq.gov/node/865373/psn-pdf
March 27, 2024 - We can look at three potential scenarios.
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psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence
August 04, 2021 - Tools/Toolkit
Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence.
Citation Text:
Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence. Houston TX; Baylor College of Medicine: 2022.
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - Missing Trauma
Citation Text:
Jurkovich GJ. Missing Trauma. 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/issue/human-factors-patient-safety-innovation
June 09, 2021 - Commentary
Human factors in patient safety as an innovation.
Citation Text:
Carayon P. Human factors in patient safety as an innovation. Appl Ergon. 2010;41(5):657-65. doi:10.1016/j.apergo.2009.12.011.
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psnet.ahrq.gov/issue/delivering-results
August 17, 2016 - Newspaper/Magazine Article
Delivering results.
Citation Text:
Delivering results. Landro L. Wall Street Journal. March 28, 2011.
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psnet.ahrq.gov/issue/disconnected
February 03, 2011 - Commentary
Disconnected.
Citation Text:
Klass P. Disconnected. N Engl J Med. 2010;362(15):1358-61. doi:10.1056/NEJMp0911193.
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psnet.ahrq.gov/issue/why-nurses-make-medication-errors-simulation-study
March 02, 2011 - Study
Why nurses make medication errors: a simulation study.
Citation Text:
Kazaoka T, Ohtsuka K, Ueno K, et al. Why nurses make medication errors: a simulation study. Nurse Educ Today. 2007;27(4):312-7.
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - First, structured diagnostic
assessments for common clinical scenarios (e.g., chest pain, fever in an
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psnet.ahrq.gov/issue/nurses-perceptions-and-experiences-communication-operating-theatre-focus-group-interview
June 22, 2009 - Study
Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview.
Citation Text:
Nestel D, Kidd J. Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview. BMC Nurs. 2006;5:1.
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