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psnet.ahrq.gov/node/49526/psn-pdf
December 01, 2006 - Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR
(Text Revision). 4th ed. … Diagnostic Criteria for Borderline Personality
*Reprinted with permission from the Diagnostic and Statistical
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psnet.ahrq.gov/web-mm/crossing-borderline
June 01, 2022 - Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision). 4th ed. … Diagnostic Criteria for Borderline Personality *Reprinted with permission from the Diagnostic and Statistical
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psnet.ahrq.gov/issue/randomized-trial-warfarin-communication-protocol-nursing-homes-sbar-based-approach
November 21, 2012 - Study
Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.
Citation Text:
Field T, Tjia J, Mazor KM, et al. Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach. Am J Med. 2011;124(2):179.e1-7. doi:1…
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psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
March 01, 2015 - are easy to assemble from routinely collected administrative datasets; they are amenable to powerful statistical … mandated and timely peer review of every in-hospital death and using continuously monitored risk-adjusted statistical
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psnet.ahrq.gov/node/46998/psn-pdf
August 01, 2019 - 10 Facts on Patient Safety.
June 27, 2018
Patient Safety and Risk Management Service Delivery and Safety. Geneva, Switzerland; World Health
Organization: August 2019.
https://psnet.ahrq.gov/issue/10-facts-patient-safety
This publication highlights statistics that illustrate the global impact of patient harm. The i…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
July 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case July 2007
Resuscitation Errors:
A Shocking Problem
Source and Credits
This presentation is based on the July 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Benjamin Abella, MD, MPhil, …
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psnet.ahrq.gov/node/837863/psn-pdf
August 17, 2022 - The Nursing Home Expert Panel’s Falls Investigation
Guide Toolkit: How-To Guide.
August 17, 2022
Portland, OR: Oregon Patient Safety Commission; 2022.
https://psnet.ahrq.gov/issue/nursing-home-expert-panels-falls-investigation-guide-toolkit-how-guide
Patient falls are common sentinel events. The latest revis…
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psnet.ahrq.gov/node/855440/psn-pdf
November 15, 2023 - NPSD Data Spotlight: Patterns of Fall Interventions.
November 15, 2023
Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-
0055.
https://psnet.ahrq.gov/issue/npsd-data-spotlight-patterns-fall-interventions
Falls are a frequently reported sentinel event. This Data Spo…
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
February 26, 2025 - RW: Of course there's a statistical problem here, where some things that are sentinel events are unusual
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psnet.ahrq.gov/node/863754/psn-pdf
March 06, 2024 - The effect of visitation restrictions on ED error.
March 6, 2024
Marks CM, Wolfe RE, Grossman SA. The effect of visitation restrictions on ED error. Intern Emerg Med.
2024;19(5):1425-1430. doi:10.1007/s11739-024-03537-3.
https://psnet.ahrq.gov/issue/effect-visitation-restrictions-ed-error
At the beginning of the C…
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psnet.ahrq.gov/issue/mortality-among-hospitalized-medicare-beneficiaries-first-2-years-following-acgme-resident
February 17, 2009 - Study
Classic
Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform.
Citation Text:
Meltzer DO, Arora VM. Evaluating Resident Duty Hour Reforms. JAMA. 2007;298(9). doi:10.1001/jama.298.9.1055.
Copy…
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psnet.ahrq.gov/node/837809/psn-pdf
August 10, 2022 - The Uneven Burden of Maternal Mortality in the U.S.
August 10, 2022
NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.
https://psnet.ahrq.gov/issue/uneven-burden-maternal-mortality-us
Preventable maternal morbidity is an ongoing challenge in the United States. This infog…
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psnet.ahrq.gov/node/60717/psn-pdf
July 22, 2020 - The U.S. is repeating its deadliest pandemic mistake.
July 22, 2020
KHAZAN OLGA. The U.S. is repeating its deadliest pandemic mistake. The Atlantic. 2020;July 6.
https://psnet.ahrq.gov/issue/us-repeating-its-deadliest-pandemic-mistake
Residential care facilities have been particularly challenged by COVID-19. This a…
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psnet.ahrq.gov/node/43340/psn-pdf
July 23, 2014 - Do doctors understand test results?
July 23, 2014
Kremer W.
https://psnet.ahrq.gov/issue/do-doctors-understand-test-results
This magazine article reports how weaknesses in physician understanding of statistics can lead to poorly
informed discussions with patients about risks and treatment options. Using actual num…
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psnet.ahrq.gov/node/764411/psn-pdf
March 02, 2022 - Nowhere is safe: record number of patients contracted
Covid in the hospital in January.
March 2, 2022
Levy R, Vestal AJ. Politico. February 19, 2022.
https://psnet.ahrq.gov/issue/nowhere-safe-record-number-patients-contracted-covid-hospital-january
Transmission of COVID-19 in the health care setting continues to b…
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psnet.ahrq.gov/node/47299/psn-pdf
March 20, 2019 - Unintentionally retained guidewires: a descriptive study
of 73 sentinel events.
March 20, 2019
Steelman VM, Thenuwara K, Shaw C, et al. Unintentionally Retained Guidewires: A Descriptive Study of 73
Sentinel Events. Jt Comm J Qual Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.003.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/72608/psn-pdf
December 23, 2020 - Incidence of Adverse Events in Indian Health Service
Hospitals.
December 23, 2020
Office of the Inspector General: Washington DC; December 2020. OIG report OEI-06-17-00530.
https://psnet.ahrq.gov/issue/incidence-adverse-events-indian-health-service-hospitals
Challenges beset safe care delivery for indigenous …
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psnet.ahrq.gov/node/864369/psn-pdf
March 13, 2024 - Telemedicine vs telephone consultations and medication
prescribing errors among referring physicians: a cluster
randomized crossover trial.
March 13, 2024
Marcin JP, Lieng MK, Mouzoon J, et al. Telemedicine vs telephone consultations and medication
prescribing errors among referring physicians: a cluster randomize…
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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - are easy to assemble from routinely collected administrative datasets; they are amenable to powerful statistical … mandated and timely peer review of every in-hospital death and using continuously monitored risk-adjusted statistical
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psnet.ahrq.gov/node/38477/psn-pdf
October 03, 2017 - Serious Adverse Events Reports.
October 3, 2017
The Quality Improvement Committee. Wellington, New Zealand; 2006-2013.
https://psnet.ahrq.gov/issue/serious-adverse-events-reports
Considered a starting point for a national reporting initiative, this series of annual reports provides statistics
on serious and sentin…