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psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overdose-pediatric-patient
October 04, 2023 - Follow-up
July 31, 2023
WebM&M Cases
Lost in Transitions
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psnet.ahrq.gov/innovations
February 26, 2025 - Postoperative Surgical Complications
(3)
Surgical Site Infections
(1)
Transitions
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psnet.ahrq.gov/node/60745/psn-pdf
October 01, 2020 - limited to16
Decreased access to clinical decision support tools for prescribing
Management of multiple transitions
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - WebM&M Cases
Steroids and Safety: Preventing Medication Adverse Events During Transitions
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.17_slideshow.ppt
June 01, 2003 - PowerPoint Presentation
Spotlight Case June 2003
Missed Appendicitis
webmm.ahrq.gov
Source and Credits
This presentation is based on June 2003
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: James Adams, MD, Fei…
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psnet.ahrq.gov/web-mm/mark-my-limb
February 10, 2015 - Mark My Limb
Citation Text:
Jacott WE, O'Leary D. Mark My Limb. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/73303/psn-pdf
May 26, 2021 - Safety Culture in EMS
May 26, 2021
Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/safety-culture-ems
Defining a Just Culture
A Just Culture is one that supports transparent and honest error reporting with the goal of fostering an
environmen…
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psnet.ahrq.gov/node/50615/psn-pdf
October 30, 2019 - Misidentifying the Unidentified – John Doe and the EHR
October 30, 2019
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
The Case
Two male patients of similar age arrived at the same …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.143_slideshow.ppt
January 01, 2015 - Spotlight Case [MONTH] 2003
Spotlight Case February 2007
The ‘Customer’ Is Always Right
Source and Credits
This presentation is based on the February 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Niraj L. Sehgal,…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
June 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case June 2004
The Wrong Shot:
Error Disclosure
Source and Credits
This presentation is based on the June 2004
AHRQ WebM&M Spotlight Case in Pediatrics
CME credit is available through the Web site
See the full article at http://webmm.ahrq.gov
Commentary by: Thomas H. …
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - SPOTLIGHT CASE
Mobility Lost in the ICU
Citation Text:
Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNot…
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psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.
Citation Text:
Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.. PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/web-mm/compare-and-contrast
July 16, 2019 - patients and informal caregivers to improve safety and facilitate person- and family-centered care during transitions
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - 16
Decreased access to clinical decision support tools for prescribing
Management of multiple transitions
-
psnet.ahrq.gov/node/861881/psn-pdf
January 31, 2024 - Quality and safety challenges arise due to gaps in
continuity of care, transitions in care, and communication
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psnet.ahrq.gov/node/837791/psn-pdf
August 05, 2022 - the implementation of evidence-based processes to
improve patient safety, especially those involving transitions
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - March 1, 2023
Information flow during pediatric trauma care transitions: things falling
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Improving patient handoffs and transitions through
adaptation and implementation of I-PASS across multiple
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psnet.ahrq.gov/node/846915/psn-pdf
March 29, 2023 - delay in
https://psnet.ahrq.gov//#12
https://psnet.ahrq.gov/issue/what-does-safety-mental-healthcare-transitions-mean-service-users-and-other-stakeholder
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - infections, emergency departments, sepsis, falls, pressure ulcers, venous thromboembolism, and care transitions