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psnet.ahrq.gov/issue/application-human-error-theory-case-analysis-wrong-procedures
November 14, 2018 - Study
Application of human error theory in case analysis of wrong procedures.
Citation Text:
Duthie EA. Application of Human Error Theory in Case Analysis of Wrong Procedures. J Patient Saf. 2010;6(2):108-114. doi:10.1097/pts.0b013e3181de47f9.
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hcup-us.ahrq.gov/db/vars/year/nedsnote.jsp
May 01, 2015 - Healthcare Cost and Utilization Project (HCUP) NEDS Notes
An official website of the Department of Health & Human Services
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psnet.ahrq.gov/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site-surgery
February 10, 2012 - Review
Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.
Citation Text:
Zahiri HR, Stromberg J, Skupsky H, et al. Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. Surg Innov. 2011;18(1):55-…
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psnet.ahrq.gov/issue/development-and-psychometric-testing-tool-measure-missed-nursing-care
August 20, 2018 - Study
Development and psychometric testing of a tool to measure missed nursing care.
Citation Text:
Kalisch BJ, Williams RA. Development and psychometric testing of a tool to measure missed nursing care. J Nurs Adm. 2009;39(5):211-9. doi:10.1097/NNA.0b013e3181a23cf5.
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psnet.ahrq.gov/issue/infection-prevention-operating-room-anesthesia-work-area
March 02, 2014 - Commentary
Infection prevention in the operating room anesthesia work area.
Citation Text:
Munoz-Price S, Bowdle A, Johnston L, et al. Infection prevention in the operating room anesthesia work area. Infect Control Hosp Epidemiol. 2018:1-17. doi:10.1017/ice.2018.303.
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/flowchart
January 01, 2023 - Flowchart
Also Known As
Activity Diagram
Cross-Functional Flowchart
Process Flowchart
Process Map
"Swim Lane" Flowchart
Examples
Common Office Visit ( PDF , 34KB)
Flowchart Incoming Calls ( PDF , 432KB)
In-Office Prescribing Flowchart - Electronic System ( PDF , 475KB)
In-O…
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hcup-us.ahrq.gov/reports/infographics/289_sud-inpatient-stays.jsp
October 01, 2022 - State Variations in Inpatient Stays for Substance Use Disorders
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psnet.ahrq.gov/issue/how-surgical-trainees-handle-catastrophic-errors-qualitative-study
March 19, 2019 - Study
How surgical trainees handle catastrophic errors: a qualitative study.
Citation Text:
Balogun JA, Bramall AN, Bernstein M. How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study. J Surg Educ. 2015;72(6):1179-84. doi:10.1016/j.jsurg.2015.05.003.
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psnet.ahrq.gov/issue/laneys-story-problem-delayed-diagnosis-pediatric-stroke
April 24, 2018 - Commentary
Laney's story: the problem of delayed diagnosis of pediatric stroke.
Citation Text:
Fitzsimons BT, Fitzsimons LL, Sun LR. Laney's Story: The Problem of Delayed Diagnosis of Pediatric Stroke. Pediatrics. 2019;143(4):e20183458. doi:10.1542/peds.2018-3458.
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psnet.ahrq.gov/issue/disclosing-medical-errors-prioritising-needs-patients-and-families
November 11, 2020 - Commentary
Disclosing medical errors: prioritising the needs of patients and families.
Citation Text:
Gallagher TH, Hemmelgarn C, Benjamin EM. Disclosing medical errors: prioritising the needs of patients and families. BMJ Qual Saf. 2023;32(10):557-561. doi:10.1136/bmjqs-2022-015880.
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hcup-us.ahrq.gov/db/state/seddrelatedreports.jsp
July 01, 2016 - SEDD Related Reports
An official website of the Department of Health & Human Services
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hcup-us.ahrq.gov/db/state/sidrelatedreports.jsp
July 01, 2016 - SID Related Reports
An official website of the Department of Health & Human Services
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hcup-us.ahrq.gov/db/nation/neds/nedsrelatedreports.jsp
June 01, 2024 - NEDS Related Reports
An official website of the Department of Health & Human Services
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/workplace-safety/workplace_safety_resource_list.pdf
October 01, 2021 - Workplace Safety Resource List
Improving Workplace Safety in Hospitals:
A Resource List for Users of the AHRQ Workplace
Safety Supplemental Items
I. Purpose
This document includes references to websites and other publicly available resources hospitals can
use to improve the extent to which their organizational …
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psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
March 22, 2009 - The Role of Health Literacy in Patient Safety
Michael S. Wolf, PhD, MPH; Stacy Cooper Bailey, MPH | March 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety…
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psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - A Statewide Collaborative to Support Vaginal Birth and
Reduce Unnecessary Cesarean Deliveries
July 8, 2022
https://psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-
cesarean-deliveries
Summary
Started in response to rising maternal morbidity and mortality rates in …
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www.ahrq.gov/sites/default/files/2024-01/basco-report.pdf
January 01, 2024 - Final Progress Report: Prescribing Errors in Ambulatory Pediatric Care
Title of Project: Prescribing Errors in Ambulatory Pediatric Care
Principal Investigator and Team Members:
Basco, William T. = PI
Simpson, Kit = Mentor
Hulsey, Thomas = Mentor, Director of Masters Degree Program
Ebeling, Myla = Co-investig…
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-10-implementation-guide.pdf
April 16, 2022 - 1
TAKEheart Hybrid Cardiac Rehabilitaton {CR) Implementation Guide - Module 10
Using Hybrid Cardiac Rehabilitation to Expand System Capacity and
Patient-Centeredness
Table of Contents
This document is hyperlinked to facilitate ease of access to the information contained inside.
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www.ahrq.gov/research/findings/final-reports/stpra/stpraapa.html
April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Appendix A. Literature Review
Previous Page Next Page
Table of Contents
Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Executive Summary
Chapter 1. Introduction
Chapter 2. ST-…
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www.ahrq.gov/cahps/quality-improvement/improvement-guide/3-are-you-ready/index.html
February 01, 2020 - Section 3: Are You Ready To Improve?
July 2015
Contents
3.A. Cultivating and Supporting QI Leaders
3.B. Organizing for Quality Improvement
3.C. Training Staff in QI Concepts and Techniques
3.D. Paying Attention to Customer Service
3.E. Recognizing and Rewarding Success
References
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