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psnet.ahrq.gov/issue/dimensions-safety-culture-systematic-review-quantitative-qualitative-and-mixed-methods
October 26, 2022 - Review
Dimensions of safety culture: a systematic review of quantitative, qualitative and mixed methods for assessing safety culture in hospitals.
Citation Text:
Churruca K, Ellis LA, Pomare C, et al. Dimensions of safety culture: a systematic review of quantitative, qualitative and mixe…
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psnet.ahrq.gov/issue/do-falls-and-other-safety-issues-occur-more-often-during-handovers-when-nurses-are-away
January 08, 2020 - Study
Do falls and other safety issues occur more often during handovers when nurses are away from patients? Findings from a retrospective study design.
Citation Text:
Demaria J, Valent F, Danielis M, et al. Do falls and other safety issues occur more often during handovers when nurses a…
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psnet.ahrq.gov/issue/nhs-learning-deaths-reports-qualitative-and-quantitative-document-analysis-first-year
February 22, 2023 - Study
NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme.
Citation Text:
Brummell Z, Vindrola-Padros C, Braun D, et al. NHS ‘Learning from Deaths’ reports: a qualitative and quantitative documen…
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psnet.ahrq.gov/issue/use-fmea-analysis-reduce-risk-errors-prescribing-and-administering-drugs-paediatric-wards
March 08, 2023 - Study
Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report.
Citation Text:
Lago P, Bizzarri G, Scalzotto F, et al. Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in p…
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psnet.ahrq.gov/issue/nature-and-timing-incidents-intercepted-surpass-checklist-surgical-patients
September 20, 2011 - Study
Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients.
Citation Text:
de Vries EN, Prins HA, Bennink C, et al. Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients. BMJ Qual Saf. 2012;21(6):503-8. doi:10.1136/…
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psnet.ahrq.gov/issue/contribution-staffing-medication-administration-errors-text-mining-analysis-incident-report
December 21, 2022 - Study
The contribution of staffing to medication administration errors: a text mining analysis of incident report data.
Citation Text:
Härkänen M, Vehviläinen‐Julkunen K, Murrells T, et al. The Contribution of Staffing to Medication Administration Errors: A Text Mining Analysis of Incide…
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psnet.ahrq.gov/issue/impact-full-personal-protective-equipment-alertness-healthcare-workers-prospective-study
August 24, 2022 - Study
Impact of full personal protective equipment on alertness of healthcare workers: a prospective study.
Citation Text:
Wells HJ, Raithatha M, Elhag S, et al. Impact of full personal protective equipment on alertness of healthcare workers: a prospective study. BMJ Open Qual. 2022;11(1…
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psnet.ahrq.gov/web-mm/pca-overdose
April 01, 2017 - PCA Overdose
Citation Text:
Doyle JD. PCA Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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psnet.ahrq.gov/node/853080/psn-pdf
August 30, 2023 - Virtual Nursing: Improving Patient Care and Meeting
Workforce Challenges
August 30, 2023
Sanford K, Schuelke S, Lee M, et al. Virtual Nursing: Improving Patient Care and Meeting Workforce
Challenges. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workf…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - Spotlight Case July 2008
Spotlight Case
Emergency Error
1
2
Source and Credits
This presentation is based on the June 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - Spotlight
Spotlight
The Consequences of Miscommunication
Regarding a Possible Artifact
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Kriti Gwal, MD
o AHRQ WebM&M Edit…
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - Medication Overdose
Citation Text:
Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/node/49709/psn-pdf
May 01, 2014 - Raise the Bar
May 1, 2014
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/raise-bar
The Case
A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The
patient was seen and evaluated by an anesthesiologist who was new to the cente…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/866846/psn-pdf
September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 24, 2024
Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/zero…
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/node/49782/psn-pdf
January 01, 2017 - A Potent Medication Administered in a Not So Viable
Route
January 1, 2017
Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
The Case
A 55-year-old man with history of nonischemic cardiomyop…
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psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - Milliliters vs. Milligrams
December 1, 2010
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
The Case
A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His
evaluation showed acu…
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psnet.ahrq.gov/node/49655/psn-pdf
June 01, 2012 - A Painful Dilemma
June 1, 2012
Davison SN. A Painful Dilemma. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/painful-dilemma
The Case
A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with
fever. She was taking propoxyphene or hydrocodone at home for pain. She h…
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psnet.ahrq.gov/node/49847/psn-pdf
November 01, 2018 - Written Signout: It Only Works If You Use The Right One
November 1, 2018
Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
The Case
A 75-year-old man was hospitalized due to a stro…