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psnet.ahrq.gov/issue/implementing-sbar-across-large-multihospital-health-system
November 23, 2014 - support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring
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psnet.ahrq.gov/issue/making-surgery-safe-it-should-be-qualitative-study
July 02, 2014 - September 24, 2016
Recommended guidelines for monitoring, reporting, and conducting research
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psnet.ahrq.gov/issue/examining-copy-and-paste-function-use-electronic-health-records
October 21, 2015 - Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring
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psnet.ahrq.gov/issue/principles-automation-patient-safety-intensive-care-learning-aviation
April 20, 2022 - Commentary
Principles of automation for patient safety in intensive care: learning from aviation.
Citation Text:
Dominiczak J, Khansa L. Principles of Automation for Patient Safety in Intensive Care: Learning From Aviation. Jt Comm J Qual Patient Saf. 2018;44(6):366-371. doi:10.1016/j.jc…
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psnet.ahrq.gov/issue/errors-breast-imaging-how-reduce-errors-and-promote-safety-environment
July 22, 2020 - Commentary
Errors in breast imaging: how to reduce errors and promote a safety environment.
Citation Text:
Sivarajah R, Dinh ML, Chetlen A. Errors in breast imaging: how to reduce errors and promote a safety environment. J Breast Imaging. 2021;3(2):221-230. doi:10.1093/jbi/wbaa118.
Cop…
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psnet.ahrq.gov/issue/prospective-study-paediatric-cardiac-surgical-microsystems-assessing-relationships-between
February 14, 2024 - support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring
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psnet.ahrq.gov/issue/non-technical-skills-surgery-during-covid-19-pandemic-observational-study
December 06, 2023 - August 12, 2020
Nonoperating room anaesthesia: safety, monitoring, cognitive aids and
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psnet.ahrq.gov/glossary
January 01, 2003 - Close Call
An event or situation that did not produce patient injury, but only because of chance. … It may reflect the quality of monitoring, the effectiveness of actions taken once early complications … Near Miss
An event or situation that did not produce patient injury, but only because of chance. … Processes encompass all that is done to patients in terms of diagnosis, treatment, monitoring, and counseling … For instance, in an emergency situation, all three of the surgical identification safety checks mentioned
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psnet.ahrq.gov/glossary-0
January 01, 2003 - Close Call
An event or situation that did not produce patient injury, but only because of chance … It may reflect the quality of monitoring, the effectiveness of actions taken once early complications … Near Miss
An event or situation that did not produce patient injury, but only because of chance … Processes encompass all that is done to patients in terms of diagnosis, treatment, monitoring, and counseling … For instance, in an emergency situation, all three of the surgical identification safety checks mentioned
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
November 01, 2011 - 16117751
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Identifying Near Misses (2)
Near misses may also be identified through active clinical monitoring … Active monitoring occurs when key data collection is built into the clinical process. … placement and including this in the medical record
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Identifying Near Misses (3)
Active clinical monitoring
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psnet.ahrq.gov/issue/does-health-care-role-and-experience-influence-perception-safety-culture-related-preventing
July 19, 2023 - February 26, 2014
A qualitative study examining the influences on situation awareness
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psnet.ahrq.gov/issue/analysis-adverse-events-associated-adult-moderate-procedural-sedation-outside-operating-room
August 13, 2014 - characteristics may help risk stratify patients, allowing for appropriate responses such as increased monitoring
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psnet.ahrq.gov/node/49784/psn-pdf
February 01, 2017 - organization to first evaluate and then select the appropriate methodology or device for the
testing situation … When patients use point-of-care testing at home, such as international normalized ratio for monitoring … Evaluate available testing methods and devices first, then select those appropriate to the testing
situation
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psnet.ahrq.gov/issue/pharmacovigilance-using-clinical-notes
April 24, 2018 - March 13, 2019
Monitoring the harm associated with use of anticoagulants in pediatric
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psnet.ahrq.gov/issue/practically-speaking-rethinking-hand-hygiene-improvement-programs-health-care-settings
September 03, 2011 - April 6, 2022
Optimizing situation awareness to reduce emergency transfers in hospitalized
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psnet.ahrq.gov/issue/supporting-perioperative-safety-during-disaster-through-clinical-crisis-education
July 05, 2017 - March 8, 2023
Automated and electronically assisted hand hygiene monitoring systems:
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psnet.ahrq.gov/issue/analysis-errors-enacted-surgical-trainees-during-skills-training-courses
August 20, 2018 - support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring
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psnet.ahrq.gov/issue/best-practices-safe-handling-products-containing-concentrated-potassium
April 22, 2011 - Study
Best practices for safe handling of products containing concentrated potassium.
Citation Text:
Tubman M, Majumdar SR, Lee D, et al. Best practices for safe handling of products containing concentrated potassium. BMJ. 2005;331(7511):274-7.
Copy Citation
Format:
Googl…
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psnet.ahrq.gov/issue/potential-benefits-and-problems-computerized-prescriber-order-entry-analysis-voluntary
January 06, 2017 - September 2, 2009
Monitoring for medication errors in outpatient settings.
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psnet.ahrq.gov/issue/primary-care-providers-opening-time-sensitive-alerts-sent-commercial-electronic-health-record
March 17, 2021 - Study
Primary care providers' opening of time-sensitive alerts sent to commercial electronic health record InBaskets.
Citation Text:
Cutrona SL, Fouayzi H, Burns L, et al. Primary Care Providers' Opening of Time-Sensitive Alerts Sent to Commercial Electronic Health Record InBaskets. J Ge…