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psnet.ahrq.gov/issue/towards-framework-select-techniques-error-prediction-supporting-novice-users-healthcare
March 28, 2011 - Review
Towards a framework to select techniques for error prediction: supporting novice users in the healthcare sector.
Citation Text:
Lyons M. Towards a framework to select techniques for error prediction: supporting novice users in the healthcare sector. Appl Ergon. 2009;40(3):379-95…
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psnet.ahrq.gov/issue/silence-kills-seven-crucial-conversations-healthcare
July 09, 2012 - Book/Report
Silence Kills: The Seven Crucial Conversations for Healthcare.
Citation Text:
Silence Kills: The Seven Crucial Conversations for Healthcare. Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A. Provo, UT: VitalSmarts, L.C; 2005.
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psnet.ahrq.gov/issue/communication-failure-basic-components-contributing-factors-and-call-structure
March 04, 2011 - Commentary
Communication failure: basic components, contributing factors, and the call for structure.
Citation Text:
Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf. 2007;33(1):34-47.
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www.ahrq.gov/antibiotic-use/acute-care/four-moments/index.html
November 01, 2019 - Four Moments of Antibiotic Decision Making
The Four Moments of Antibiotic Decision Making are the critical time periods of antibiotic decision making. Clinicians are encouraged to use the Four Moments framework for all patients receiving antibiotics and whenever the need for antibiotics is being considered.
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psnet.ahrq.gov/issue/silent-epidemic-health-effects-illiteracy
January 12, 2011 - Commentary
The silent epidemic--the health effects of illiteracy.
Citation Text:
Marcus EN. The silent epidemic--the health effects of illiteracy. N Engl J Med. 2006;355(4):339-41.
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psnet.ahrq.gov/issue/preventing-vincristine-administration-errors-does-evidence-support-minibag-infusions
January 01, 2008 - Commentary
Preventing vincristine administration errors: does evidence support minibag infusions?
Citation Text:
Mahon SM, Schulmeister L. Preventing Vincristine Administration Errors: Does Evidence Support Minibag Infusions? Clin J Oncol Nurs. 2006;10(2). doi:10.1188/06.cjon.271-273. …
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www.ahrq.gov/faqs/index.html?page=27
June 12, 2025 - Frequently Asked Questions
Check to find the answers to your questions about the Agency for Healthcare Research and Quality (AHRQ)
programs and activities. You can search by category or key words. You can also send us your questions or website
feedback here. We will respond to your requests based on the bes…
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psnet.ahrq.gov/issue/second-victim-traumatic-experience
October 06, 2016 - Commentary
Second victim: a traumatic experience.
Citation Text:
Second victim: a traumatic experience. Wands B. AANA J. 2021;89(2):168-174.
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psnet.ahrq.gov/issue/safer-electronic-health-records-safety-assurance-factors-ehr-resilience
December 20, 2017 - Book/Report
SAFER Electronic Health Records: Safety Assurance Factors for EHR Resilience.
Citation Text:
SAFER Electronic Health Records: Safety Assurance Factors for EHR Resilience. Sittig DF, Singh H, eds. Waretown, NJ: Apple Academic Press; 2015. ISBN: 9781771881173.
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psnet.ahrq.gov/issue/communication-patterns-uk-emergency-department
June 17, 2010 - Study
Communication patterns in a UK emergency department.
Citation Text:
Woloshynowych M, Davis R, Brown R, et al. Communication patterns in a UK emergency department. Ann Emerg Med. 2007;50(4):407-13.
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www.ahrq.gov/news/newsroom/case-studies/201506.html
April 01, 2015 - Penn Medicine Chester County Hospital Implements AHRQ Toolkit to Reduce Readmissions
Search All Impact Case Studies
April 2015
Penn Medicine Chester County Hospital, a 257-bed complex in West Chester, Pennsylvania, part of the University of Pennsylvania Health System, was one of 10 hospitals involved in AHR…
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psnet.ahrq.gov/issue/patient-safety-investigation-report-services-university-hospital-galway-uhg-and-reflected
June 14, 2017 - Book/Report
Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the care provided to Savita Halappanavar.
Citation Text:
Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the ca…
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psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients
July 10, 2008 - Review
Disclosing harmful medical errors to patients.
Citation Text:
Gallagher TH, Studdert DM, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356(26):2713-9.
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psnet.ahrq.gov/issue/answers-improved-medication-reconciliation-lie-pharmacists
June 13, 2011 - Newspaper/Magazine Article
Answers to improved medication reconciliation lie with pharmacists.
Citation Text:
Answers to improved medication reconciliation lie with pharmacists. Barbella M. Drug Topics. November 19, 2007.
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psnet.ahrq.gov/issue/diagnostic-safety-toolkit
December 05, 2024 - Toolkit
Diagnostic Safety Toolkit.
Citation Text:
Child Health Patient Safety Organization. Diagnostic Safety Toolkit. Washington DC: Children's Hospital Association. May 2020.
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psnet.ahrq.gov/issue/reliability-uncertainty-and-management-error-new-perspectives-covid-19-era
January 12, 2022 - Commentary
Reliability, uncertainty and the management of error: new perspectives in the COVID-19 era.
Citation Text:
Schulman PR. Reliability, uncertainty and the management of error: new perspectives in the COVID‐19 era. J Contingencies Crisis Manage. 2022;30(1):92-101. doi:10.1111/146…
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www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/cusp-approach.html
October 01, 2024 - MRSA Prevention Toolkit: ICUs & Non-ICUs
Why Choose a CUSP Approach?
Previous Page Next Page
Table of Contents
MRSA Prevention Toolkit: ICUs & Non-ICUs
The Four Key Strategies of MRSA Prevention
The Importance of MRSA Prevention
Decolonization
Tools & Resources for Decolonization
Tools & R…
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psnet.ahrq.gov/issue/2011-john-m-eisenberg-patient-safety-and-quality-awards
November 19, 2018 - Award Recipient
2011 John M. Eisenberg Patient Safety and Quality Awards.
Citation Text:
2011 John M. Eisenberg Patient Safety and Quality Awards. Jt Comm J Qual Patient Saf. 2012;38(7):289-327.
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psnet.ahrq.gov/issue/bar-coding-patient-safety
February 12, 2020 - Commentary
Bar coding for patient safety.
Citation Text:
Wright AA, Katz IT. Bar coding for patient safety. N Engl J Med. 2005;353(4):329-31.
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www.ahrq.gov/hai/cusp/toolkit/observing-rounds.html
December 01, 2012 - Observing Patient Care Rounds
CUSP Toolkit
Communication among disciplines can be improved if viewed through the eyes of an objective observer.
Problem statement: Interdisciplinary rounds are in the best interest of patients. Poor communication among staff is a root cause of many patient adverse and sentin…