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psnet.ahrq.gov/web-mm/case-patient-flow-management
February 23, 2019 - Patient flow variability and unplanned readmissions to an intensive care unit.
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psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
August 05, 2009 - After the surgery, the surgeon briefed the patient in the post-anesthesia care unit (PACU) on his findings
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - own residency program revealed that patients of residents who were on an all-consuming intensive care unit
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psnet.ahrq.gov/web-mm/reaction-dye
March 01, 2007 - beginning with 40 mg furosemide), and be moved to an emergency department (or, for inpatients, a monitored unit
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psnet.ahrq.gov/node/846563/psn-pdf
March 21, 2023 - Schwartz Rounds are facilitated, unit-based conversations during which staff can
discuss the emotional
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psnet.ahrq.gov/primer/long-term-care-and-patient-safety
February 24, 2022 - or critically ill, most commonly recovering from a hospitalization that included an intensive care unit
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psnet.ahrq.gov/node/49400/psn-pdf
May 01, 2003 - catheter-related venous thrombosis
Case & Commentary: Part 1
An 8-month-old girl had been in the intensive care unit
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psnet.ahrq.gov/periodic-issue/periodic-issue-469
December 31, 2024 - and appropriate treatment for hypertensive emergencies in the emergency department and intensive care unit
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psnet.ahrq.gov/node/39679/psn-pdf
January 19, 2011 - Coping with medical error: a systematic review of papers
to assess the effects of involvement in medical errors on
healthcare professionals' psychological well-being.
January 19, 2011
Sirriyeh R, Lawton R, Gardner P, et al. Coping with medical error: a systematic review of papers to assess
the effects of involveme…
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psnet.ahrq.gov/node/37613/psn-pdf
March 12, 2008 - Implementing patient safety interventions in your
hospital: what to try and what to avoid.
March 12, 2008
Ranji SR, Shojania KG. Implementing patient safety interventions in your hospital: what to try and what to
avoid. Med Clin North Am. 2008;92(2):275-93, vii-viii. doi:10.1016/j.mcna.2007.10.007.
https://psnet.a…
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psnet.ahrq.gov/node/40618/psn-pdf
August 27, 2012 - Predictors of likelihood of speaking up about safety
concerns in labour and delivery.
August 27, 2012
Lyndon A, Sexton B, Simpson KR, et al. Correction. BMJ Qual Saf. 2011;22(2):791-799.
doi:10.1136/bmjqs.2010.050211.
https://psnet.ahrq.gov/issue/predictors-likelihood-speaking-about-safety-concerns-labour-and-deli…
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psnet.ahrq.gov/node/47210/psn-pdf
November 16, 2018 - A multi-stakeholder consensus-driven research agenda
for better understanding and supporting the emotional
impact of harmful events on patients and families.
November 16, 2018
Bell SK, Etchegaray J, Gaufberg E, et al. A Multi-Stakeholder Consensus-Driven Research Agenda for
Better Understanding and Supporting the …
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psnet.ahrq.gov/node/45714/psn-pdf
December 20, 2017 - US emergency department visits for outpatient adverse
drug events, 2013–2014.
December 20, 2017
Shehab N, Lovegrove MC, Geller AI, et al. US Emergency Department Visits for Outpatient Adverse Drug
Events, 2013-2014. JAMA. 2016;316(20):2115-2125. doi:10.1001/jama.2016.16201.
https://psnet.ahrq.gov/issue/us-emergenc…
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psnet.ahrq.gov/node/43115/psn-pdf
December 18, 2014 - Multistate point-prevalence survey of health care-
associated infections.
December 18, 2014
Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated
infections. N Engl J Med. 2014;370(13):1198-208. doi:10.1056/NEJMoa1306801.
https://psnet.ahrq.gov/issue/multistate-point…
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psnet.ahrq.gov/node/42923/psn-pdf
September 26, 2017 - Assessing the state of safe medication practices using
the ISMP Medication Safety Self Assessment for
Hospitals: 2000 and 2011.
September 26, 2017
Vaida AJ, Lamis RL, Smetzer JL, et al. Assessing the State of Safe Medication Practices Using the ISMP
Medication Safety Self Assessment ® for Hospitals: 2000 and 2011.…
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psnet.ahrq.gov/node/47908/psn-pdf
April 24, 2019 - "Sorry" is never enough: how state apology laws fail to
reduce medical malpractice liability risk.
April 24, 2019
McMichael BJ, Van Horn L, Viscusi K. "Sorry” Is Never Enough: How State Apology Laws Fail to Reduce
Medical Malpractice Liability Risk. Stanford Law Rev. 2019;71(2):341-409.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/46493/psn-pdf
January 24, 2019 - Four states with robust prescription drug monitoring
programs reduced opioid dosages.
January 24, 2019
Haffajee RL, Mello MM, Zhang F, et al. Four States With Robust Prescription Drug Monitoring Programs
Reduced Opioid Dosages. Health Aff (Millwood). 2018;37(6):964-974. doi:10.1377/hlthaff.2017.1321.
https://psnet…
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psnet.ahrq.gov/node/45385/psn-pdf
January 03, 2017 - Viewing prevention of catheter-associated urinary tract
infection as a system: using systems engineering and
human factors engineering in a quality improvement
project in an academic medical center.
January 3, 2017
Rhee C, Phelps E, Meyer B, et al. Viewing Prevention of Catheter-Associated Urinary Tract Infection …
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psnet.ahrq.gov/node/46394/psn-pdf
August 29, 2018 - Sustained user engagement in health information
technology: the long road from implementation to system
optimization of computerized physician order entry and
clinical decision support systems for prescribing in
hospitals in England.
August 29, 2018
Cresswell K, Lee L, Mozaffar H, et al. Sustained User Engagement…
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psnet.ahrq.gov/node/47742/psn-pdf
February 20, 2019 - AHRQ Nursing Home Survey on Patient Safety Culture:
2019 User Comparative Database Report.
February 20, 2019
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality;
February 2019. AHRQ Publication No. 19-0027-EF.
https://psnet.ahrq.gov/issue/ahrq-nursing-home-survey-patient-…