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psnet.ahrq.gov/issue/disclosing-adverse-events-patients
September 23, 2020 - Commentary
Disclosing adverse events to patients.
Citation Text:
Cantor MD, Barach P, Derse A, et al. Disclosing adverse events to patients. Jt Comm J Qual Patient Saf. 2005;31(1):5-12.
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digital.ahrq.gov/track-6-using-reporting-systems-safety-and-quality-improvement
January 01, 2023 - Let us know the nature of the problem, the Web address of what you want, and your contact information
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psnet.ahrq.gov/issue/risk-models-improve-safety-dispensing-high-alert-medications-community-pharmacies
December 02, 2020 - Study
Risk models to improve safety of dispensing high-alert medications in community pharmacies.
Citation Text:
Cohen MR, Smetzer JL, Westphal JE, et al. Risk models to improve safety of dispensing high-alert medications in community pharmacies. J Am Pharm Assoc (2003). 2012;52(5):584-6…
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psnet.ahrq.gov/issue/shot-annual-report-2019
July 10, 2019 - Book/Report
SHOT Annual Report.
Citation Text:
SHOT Annual Report. S Narayan, ed. Manchester, UK: Serious Hazards of Transfusion (SHOT) Steering Group; 2023. ISBN: 9781999596859.
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psnet.ahrq.gov/issue/ambiguities-chronic-illness-management-and-challenges-medical-error-paradigm
July 02, 2014 - Study
Ambiguities of chronic illness management and challenges to the medical error paradigm.
Citation Text:
Lutfey KE, Freese J. Ambiguities of chronic illness management and challenges to the medical error paradigm. Soc Sci Med. 2007;64(2):314-25.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state2.html
January 01, 2024 - of domains and subdomains, identify any gaps not highlighted in our findings, and determine how to address
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psnet.ahrq.gov/issue/misinformation-medical-literature-what-role-do-error-and-fraud-play
November 02, 2011 - Commentary
Misinformation in the medical literature: what role do error and fraud play?
Citation Text:
Steen G. Misinformation in the medical literature: what role do error and fraud play? J Med Ethics. 2011;37(8):498-503. doi:10.1136/jme.2010.041830.
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psnet.ahrq.gov/issue/near-miss-event-analysis-enhances-barcode-medication-administration-process
February 13, 2013 - Newspaper/Magazine Article
Near-miss event analysis enhances the barcode medication administration process.
Citation Text:
Near-miss event analysis enhances the barcode medication administration process. Magee MC; Miller K; Patzek D; Madera C; Michalek C; Shetterly M.
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www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/perioperative-asst.html
December 01, 2017 - Once defects have been clearly identified, you can design a quality improvement intervention to address
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psnet.ahrq.gov/issue/systems-approach-patient-centered-care
November 21, 2021 - Commentary
A systems approach to patient-centered care.
Citation Text:
Bergeson SC, Dean JD. A systems approach to patient-centered care. JAMA. 2006;296(23):2848-51.
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psnet.ahrq.gov/issue/drug-shortages-0
February 22, 2023 - Review
Drug shortages.
Citation Text:
Drug shortages. Aronson JK, Heneghan C, Ferner RE. Br J Clin Pharmacol. 2023;89(10):2950-2963.
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit1-2.html
November 01, 2014 - Lean was selected as a complement to Six Sigma to address an identified gap in tools targeting process
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-2.html
November 01, 2014 - Lean was selected as a complement to Six Sigma to address an identified gap in tools targeting process
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psnet.ahrq.gov/issue/simulation-ward-processes-surgical-care
June 17, 2015 - Commentary
Simulation for ward processes of surgical care.
Citation Text:
Pucher PH, Darzi A, Aggarwal R. Simulation for ward processes of surgical care. Am J Surg. 2013;206(1):96-102. doi:10.1016/j.amjsurg.2012.08.013.
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psnet.ahrq.gov/issue/night-and-day-shedding-light-hours-care
September 28, 2010 - Commentary
Like night and day — shedding light on off-hours care.
Citation Text:
Shulkin DJ. Like night and day--shedding light on off-hours care. N Engl J Med. 2008;358(20):2091-3. doi:10.1056/NEJMp0707144.
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psnet.ahrq.gov/issue/reducing-cognitive-errors-dermatology-can-anything-be-done
September 29, 2010 - Commentary
Reducing cognitive errors in dermatology: can anything be done?
Citation Text:
Dunbar M, Helms SE, Brodell RT. Reducing cognitive errors in dermatology: can anything be done? J Am Acad Dermatol. 2013;69(5):810-813. doi:10.1016/j.jaad.2013.07.008.
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module3/guide.html
March 01, 2017 - Explain how to address and overcome challenges to staff empowerment.
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psnet.ahrq.gov/issue/new-covid-boosters-look-lot-old-ones-doctors-worry-could-lead-errors
April 26, 2023 - Newspaper/Magazine Article
New Covid boosters look a lot like the old ones. Doctors worry that could lead to errors.
Citation Text:
New Covid boosters look a lot like the old ones. Doctors worry that could lead to errors. Lovelace Jr, B. NBC News. September 7, 2022.
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www.ahrq.gov/research/findings/evidence-based-reports/gapkaleidtp.html
April 01, 2018 - effectiveness of bundled payment programs, effectiveness of the patient-centered medical home, QI strategies to address
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www.ahrq.gov/sites/default/files/wysiwyg/funding/training-grants/trainover.pdf
January 01, 2009 - The Agency’s research portfolios contribute
to this mission and address:
Patient safety.