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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - Medication administration errors are typically thought of as a failure in one of the five “rights” of
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psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - In many cases, these influences go unnoticed or are not given much thought.
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digital.ahrq.gov/sites/default/files/Innovation%20Center%20Quarterly%20Report%20Three_508_Jan26.pdf
January 01, 2024 - Planning Committee
The Innovation Center Planning Committee comprises seven thought leaders in the field
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psnet.ahrq.gov/web-mm/code-blue-where
March 30, 2020 - requires that a hospital's dedicated emergency department would not only encompass what is generally thought
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psnet.ahrq.gov/web-mm/complaints-safety-surveillance
May 05, 2021 - The nurse thought it unusual to increase the pain medication so much, but she remembered that this hospitalist
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psnet.ahrq.gov/node/49669/psn-pdf
November 01, 2012 - level of 8 g/dL or
less, or symptoms of anemia related to coronary artery disease (e.g., chest pain thought
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psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
January 29, 2020 - Some team members who saw the positive result in the medical record erroneously thought that Listeria
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www.ahrq.gov/sites/default/files/2025-03/smith2-report.pdf
January 01, 2025 - A striking feature of human and other primate cognition is our propensity to
categorize.1 This is thought
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psnet.ahrq.gov/web-mm/worst-headache
July 01, 2016 - At first, the physician thought she had simply hung up, but since it was rather abrupt he called back
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psnet.ahrq.gov/web-mm/triage-time-bomb
September 01, 2008 - Triage Time Bomb
Citation Text:
Washington DL. Triage Time Bomb. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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psnet.ahrq.gov/web-mm/say-it-again
January 31, 2020 - Say It Again
Citation Text:
Henriksen K, Hall KK. Say It Again. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
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…
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psnet.ahrq.gov/node/33731/psn-pdf
June 01, 2012 - An American View of the UK's Patient Safety Enterprise:
Top Down vs. Bottom Up
June 1, 2012
Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
Perspecti…
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psnet.ahrq.gov/node/33733/psn-pdf
July 01, 2012 - Patient Safety and Health Information Technology:
Learning from Our Mistakes
July 1, 2012
Koppel R. Patient Safety and Health Information Technology: Learning from Our Mistakes. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
Perspe…
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psnet.ahrq.gov/node/49433/psn-pdf
June 23, 2021 - Environmental Safety in the OR
February 1, 2004
Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/environmental-safety-or
The Case
The infection control department of a hospital noticed a marked increase in the rates of post-operative
sternal wound inf…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/127-roles-responsibilities-tool.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Core Comprehensive Unit-based Safety Program (CUSP) Team Member
Roles & Responsibilities
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
How To Use This Tool
This tool identifies core CUSP team members and describes indi…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/147-cusp-roles-responsibilities-tool.docx
June 02, 2025 - AHRQ Safety Program for MRSA Prevention
Core CUSP Team Member
Roles & Responsibilities
How To Use This Tool
This tool identifies core Comprehensive Unit-based Safety Program (CUSP) team members and describes individual roles and responsibilities.
For best results, each team member should:
· Review expectations associa…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams-6.html
July 01, 2023 - Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety
Core Principles for the PCA Diagnostic Team
Previous Page Next Page
Table of Contents
Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety
Introduc…
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psnet.ahrq.gov/node/33583/psn-pdf
March 01, 2023 - testing new equipment and technology under real-world conditions, and clinical systems
testing can be thought
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool11_comm_resource.docx
June 02, 2025 - This can also be a useful supplemental method of research for resources you may not have thought of.
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psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
July 17, 2024 - Review how to balance systems thinking with individual accountability in health care. … I thought you would want know the final diagnosis."