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psnet.ahrq.gov/node/849595/psn-pdf
May 31, 2023 - Effect of an emergency department process improvement
package on suicide prevention: the ED-SAFE 2 cluster
randomized clinical trial.
May 31, 2023
Boudreaux ED, Larkin C, Vallejo Sefair A, et al. Effect of an emergency department process improvement
package on suicide prevention: the ED-SAFE 2 cluster randomized c…
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psnet.ahrq.gov/node/43140/psn-pdf
October 31, 2014 - The frequency of diagnostic errors in outpatient care:
estimations from three large observational studies
involving US adult populations.
October 31, 2014
Singh H, Meyer AND, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from
three large observational studies involving US adult popu…
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psnet.ahrq.gov/node/41095/psn-pdf
February 01, 2012 - Intervention to reduce transmission of resistant bacteria
in intensive care.
February 1, 2012
Huskins C, Huckabee CM, O'Grady NP, et al. Intervention to reduce transmission of resistant bacteria in
intensive care. N Engl J Med. 2011;364(15):1407-18. doi:10.1056/NEJMoa1000373.
https://psnet.ahrq.gov/issue/intervent…
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psnet.ahrq.gov/node/40600/psn-pdf
September 09, 2011 - To make or buy patient safety solutions: a resource
dependence and transaction cost economics perspective.
September 9, 2011
Fareed N, Mick SS. To make or buy patient safety solutions: a resource dependence and transaction cost
economics perspective. Health Care Manage Rev. 2011;36(4):288-298.
doi:10.1097/HMR.0b01…
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psnet.ahrq.gov/node/72824/psn-pdf
March 10, 2021 - Association of a Safety Program for Improving Antibiotic
Use with antibiotic use and hospital-onset Clostridioides
difficile infection rates among US hospitals
March 10, 2021
Tamma PD, Miller MA, Dullabh P, et al. Association of a safety program for improving antibiotic use with
antibiotic use and hospital-onset C…
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psnet.ahrq.gov/node/47457/psn-pdf
January 17, 2019 - Developing a reporting culture: learning from close calls
and hazardous conditions.
January 17, 2019
Developing a reporting culture: Learning from close calls and hazardous conditions. Sentinel Event Alert.
2018;(60):1-8.
https://psnet.ahrq.gov/issue/developing-reporting-culture-learning-close-calls-and-hazardous-…
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psnet.ahrq.gov/node/42326/psn-pdf
June 05, 2013 - Patient safety event reporting expectation: does it
influence residents' attitudes and reporting behaviors?
June 5, 2013
Boike JR, Bortman JS, Radosta JM, et al. Patient safety event reporting expectation: does it influence
residents' attitudes and reporting behaviors? J Patient Saf. 2013;9(2):59-67.
doi:10.1097/P…
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psnet.ahrq.gov/node/46531/psn-pdf
January 24, 2019 - Tracking progress in improving diagnosis: a framework
for defining undesirable diagnostic events.
January 24, 2019
Olson A, Graber ML, Singh H. Tracking Progress in Improving Diagnosis: A Framework for Defining
Undesirable Diagnostic Events. J Gen Intern Med. 2018;33(7):1187-1191. doi:10.1007/s11606-018-4304-2.
ht…
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psnet.ahrq.gov/node/43904/psn-pdf
October 13, 2015 - Reducing unacceptable missed doses: pharmacy
assistant–supported medicine administration.
October 13, 2015
Baqir W, Jones K, Horsley W, et al. Reducing unacceptable missed doses: pharmacy assistant-supported
medicine administration. Int J Pharm Pract. 2015;23(5):327-332. doi:10.1111/ijpp.12172.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/46236/psn-pdf
April 03, 2018 - The impact of a diagnostic decision support system on
the consultation: perceptions of GPs and patients.
April 3, 2018
Porat T, Delaney B, Kostopoulou O. The impact of a diagnostic decision support system on the
consultation: perceptions of GPs and patients. BMC Med Inform Decis Mak. 2017;17(1):79.
doi:10.1186/s12…
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www.ahrq.gov/hai/tools/clabsi-cauti-icu/overcome/engagement.html
April 01, 2022 - Team Engagement
To make sustainable quality improvements, you need to recruit an enthusiastic team and keep members engaged by providing the relevant data, inviting team feedback, and creating necessary incentives. Accomplishing this will take time and frequent evaluation. Although the nuances of your approach …
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psnet.ahrq.gov/node/41924/psn-pdf
April 05, 2013 - Disclosure-and-resolution programs that include
generous compensation offers may prompt a complex
patient response.
April 5, 2013
Murtagh L, Gallagher TH, Andrew P, et al. Disclosure-and-resolution programs that include generous
compensation offers may prompt a complex patient response. Health Aff (Millwood). 2012…
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psnet.ahrq.gov/node/45992/psn-pdf
January 01, 2020 - Barriers and facilitators of adverse event reporting by
adolescent patients and their families.
March 29, 2017
Sawhney PN, Davis LS, Daraiseh NM, et al. Barriers and Facilitators of Adverse Event Reporting by
Adolescent Patients and Their Families. J Patient Saf. 2020;16(3):232-237.
doi:10.1097/pts.000000000000029…
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/impact-grants/index.html
August 01, 2015 - AHRQ Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Grants
Project Profiles
Each grant title below links to a short profile about the project. The profiles include an overview of the efforts to spread primary care transformation within the model State, efforts to disseminate the mod…
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psnet.ahrq.gov/node/40200/psn-pdf
July 02, 2014 - Checklists to reduce diagnostic errors.
July 2, 2014
Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med. 2011;86(3):307-313.
doi:10.1097/ACM.0b013e31820824cd.
https://psnet.ahrq.gov/issue/checklists-reduce-diagnostic-errors
Diagnostic errors are rapidly gaining attention as the next f…
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psnet.ahrq.gov/node/45955/psn-pdf
January 01, 2021 - The essential role of leadership in developing a safety
culture.
April 3, 2017
The essential role of leadership in developing a safety culture. Sentinel Event Alert. 2021;57(57):1-8.
https://psnet.ahrq.gov/issue/essential-role-leadership-developing-safety-culture
The Joint Commission issues sentinel event alerts t…
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psnet.ahrq.gov/node/41795/psn-pdf
September 07, 2016 - Drug shortage-associated increase in catheter-related
blood stream infection in children.
September 7, 2016
Ralls MW, Blackwood A, Arnold MA, et al. Drug shortage-associated increase in catheter-related blood
stream infection in children. Pediatrics. 2012;130(5):e1369-73. doi:10.1542/peds.2011-3894.
https://psnet.…
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psnet.ahrq.gov/node/41610/psn-pdf
January 25, 2017 - Adverse events among children in Canadian hospitals:
the Canadian Paediatric Adverse Events Study.
January 25, 2017
Matlow A, Baker R, Flintoft V, et al. Adverse events among children in Canadian hospitals: the Canadian
Paediatric Adverse Events Study. CMAJ. 2012;184(13):E709-718. doi:10.1503/cmaj.112153.
https://…
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psnet.ahrq.gov/node/40271/psn-pdf
May 25, 2011 - Collaborative cohort study of an intervention to reduce
ventilator-associated pneumonia in the intensive care
unit.
May 25, 2011
Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce
ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidem…
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psnet.ahrq.gov/node/849124/psn-pdf
May 17, 2023 - Human factors and safety analysis methods used in the
design and redesign of electronic medication
management systems: a systematic review.
May 17, 2023
Awad S, Amon K, Baillie A, et al. Human factors and safety analysis methods used in the design and
redesign of electronic medication management systems: a systema…