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psnet.ahrq.gov/issue/data-consistency-voluntary-medical-incident-reporting-system
August 21, 2024 - Study
Data consistency in a voluntary medical incident reporting system.
Citation Text:
Gong Y. Data consistency in a voluntary medical incident reporting system. J Med Syst. 2011;35(4):609-15. doi:10.1007/s10916-009-9398-y.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops-101-webcast-overview-surveys.pdf
January 01, 2022 - Understanding SOPS® Surveys: A Primer for New Users - Gray
Overview of the SOPS Surveys
Laura Gray, MPH
Senior Study Director
User Network for the AHRQ Surveys on Patient Safety Culture (SOPS)
Westat
What is Patient Safety Culture?
Organization
13
What are the SOPS Surveys?
• Surveys of providers and st…
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psnet.ahrq.gov/issue/evaluation-measure-dx-resource-accelerate-diagnostic-safety-learning-and-improvement
February 07, 2024 - Study
Evaluation of Measure Dx, a resource to accelerate diagnostic safety learning and improvement.
Citation Text:
Bradford A, Tran A, Ali KJ, et al. Evaluation of Measure Dx, a resource to accelerate diagnostic safety learning and improvement. J Gen Intern Med. . 2024;Epub Oct 22. doi:…
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digital.ahrq.gov/ahrq-funded-projects/age-friendly-learning-healthcare-system-transformative-digital-solution
April 01, 2024 - An Age-Friendly Learning Healthcare System: A Transformative Digital Solution for Geriatrics Clinics
Project Description
Integrated, interoperable, point-of-care digital tools hold promise for enhancing shared decision-making in Age-Friendly care, advancing clinical practice, a…
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www.ahrq.gov/news/newsroom/case-studies/201901.html
March 01, 2019 - Georgetown University Family Nurse Practitioner Program Trains Hundreds of Students Using AHRQ App to Improve Primary Care
Search All Impact Case Studies
March 2019
Approximately 600 students who have completed a Georgetown University masters’ level course for family nurse practitioners use an electronic ap…
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psnet.ahrq.gov/issue/controlled-substance-drug-diversion-healthcare-workers-threat-patient-safety
April 05, 2023 - Special or Theme Issue
Controlled substance drug diversion by healthcare workers as a threat to patient safety.
Citation Text:
Controlled substance drug diversion by healthcare workers as a threat to patient safety. ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4…
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psnet.ahrq.gov/issue/toward-translation-systems-thinking-methods-patient-safety-practice-assessing-validity-net
April 21, 2021 - Study
Toward the translation of systems thinking methods in patient safety practice: assessing the validity of Net-HARMS and AcciMap.
Citation Text:
Salmon PM, King B, Hulme A, et al. Toward the translation of systems thinking methods in patient safety practice: assessing the validity of…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/113-cleaning-monitoring-methods-one-pager.docx
April 01, 2025 - In the patient care environment, quality of cleaning can be measured by which and what percentage of high-touch surfaces (HTS) are adequately cleaned and disinfected. Below, the four most common methods of monitoring are discussed, including their pros and cons.
Observation1-3
· A supervisor or trained staff conducts …
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psnet.ahrq.gov/issue/hidden-flaws-behind-expert-level-accuracy-multimodal-gpt-4-vision-medicine
March 24, 2019 - Study
Hidden flaws behind expert-level accuracy of multimodal GPT-4 vision in medicine.
Citation Text:
Jin Q, Chen F, Zhou Y, et al. Hidden flaws behind expert-level accuracy of multimodal GPT-4 vision in medicine. NPJ Dig Med. 2024;7(1):190. doi:10.1038/s41746-024-01185-7.
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psnet.ahrq.gov/issue/debriefing-emergency-department-after-clinical-events-practical-guide
November 16, 2022 - Commentary
Debriefing in the emergency department after clinical events: a practical guide.
Citation Text:
Kessler DO, Cheng A, Mullan PC. Debriefing in the Emergency Department After Clinical Events: A Practical Guide. Ann Emerg Med. 2015;65(6):690-698. doi:10.1016/j.annemergmed.2014.10…
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digital.ahrq.gov/ahrq-funded-projects/improving-guideline-development-and-implementation/annual-summary/2010
January 01, 2010 - Improving Guideline Development and Implementation - 2010
Project Name
Improving Guideline Development and Implementation
Principal Investigator
Shiffman, Richard N.
Organization
Yale University
Contract Number
09-587F-07
Project Period
September 2006 – Sept…
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digital.ahrq.gov/ahrq-funded-projects/improving-guideline-development-and-implementation/annual-summary/2011
January 01, 2011 - Improving Guideline Development and Implementation - 2011
Project Name
Improving Guideline Development and Implementation
Principal Investigator
Shiffman, Richard N.
Organization
Yale University
Contract Number
09-587F-07
Project Period
September 2006 - Febr…
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psnet.ahrq.gov/issue/patients-and-physicians-attitudes-regarding-disclosure-medical-errors
March 21, 2017 - Study
Classic
Patients' and physicians' attitudes regarding the disclosure of medical errors.
Citation Text:
Gallagher TH, Waterman AD, Ebers AG, et al. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-7.
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/UnktCMhwyLMX5rmYEV-m8c
December 01, 2020 - Screening for Iron Deficiency Anemia and Iron Supplementation in Pregnant Women: USPSTF Literature Surveillance Report
1
U.S. Preventive Services Task Force
Literature Surveillance Report
Title: Screening for iron deficiency anemia and iron supplementation in pregnant women to improve
maternal healt…
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psnet.ahrq.gov/issue/adverse-drug-event-rates-high-cost-and-high-use-drugs-intensive-care-unit
April 11, 2012 - Study
Adverse-drug-event rates for high-cost and high-use drugs in the intensive care unit.
Citation Text:
Kane-Gill SL, Rea RS, Verrico MM, et al. Adverse-drug-event rates for high-cost and high-use drugs in the intensive care unit. Am J Health Syst Pharm. 2006;63(19):1876-81.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/128-what-are-4es-one-pager.docx
April 01, 2025 - The 4 Es framework identifies four important elements when implementing patient safety interventions: Engage, Educate, Execute, and Evaluate. This framework integrates well with the Comprehensive Unit-based Safety Program (CUSP) and addresses both the technical objectives of improving practices and the adaptive objecti…
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psnet.ahrq.gov/issue/improving-safety-medication-administration-using-interactive-cd-rom-program
February 15, 2011 - Commentary
Improving the safety of medication administration using an interactive CD-ROM program.
Citation Text:
Schneider PJ, Pedersen CA, Montanya KR, et al. Improving the safety of medication administration using an interactive CD-ROM program. Am J Health Syst Pharm. 2006;63(1):59-6…
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psnet.ahrq.gov/issue/harnessing-power-medical-malpractice-data-improve-patient-care
September 25, 2019 - Commentary
Harnessing the power of medical malpractice data to improve patient care.
Citation Text:
Siegal D, Swift J, Forget J, et al. Harnessing the power of medical malpractice data to improve patient care. J Healthc Risk Manag. 2020;39(3):28-36. doi:10.1002/jhrm.21393.
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psnet.ahrq.gov/issue/confidential-reporting-patient-safety-events-primary-care-results-multilevel-classification
April 07, 2021 - Study
Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive and system factors.
Citation Text:
Kostopoulou O, Delaney B. Confidential reporting of patient safety events in primary care: results from a multilevel classific…
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psnet.ahrq.gov/issue/development-swarm-model-high-reliability-rapid-problem-solving-and-institutional-learning
November 16, 2022 - Commentary
Development of "SWARM" as a model for high reliability, rapid problem solving, and institutional learning.
Citation Text:
Williams EA, Nikolai DA, Ladwig L, et al. Development of "SWARM" as a Model for High Reliability, Rapid Problem Solving, and Institutional Learning. Jt Com…