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psnet.ahrq.gov/issue/teaching-medical-students-recognise-and-report-errors
March 01, 2023 - Commentary
Teaching medical students to recognise and report errors.
Citation Text:
Mohsin SU, Ibrahim Y, Levine D. Teaching medical students to recognise and report errors. BMJ Open Qual. 2019;8(2):e000558. doi:10.1136/bmjoq-2018-000558.
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psnet.ahrq.gov/issue/when-theres-no-one-whom-error-can-be-disclosed-how-should-error-be-handled
March 19, 2018 - Commentary
When there's no one to whom an error can be disclosed, how should an error be handled?
Citation Text:
Chiu RG. When There's No One to Whom an Error Can Be Disclosed, How Should an Error Be Handled? AMA J Ethics. 2019;21(7):E553-558. doi:10.1001/amajethics.2019.553.
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psnet.ahrq.gov/issue/surgical-simulation-curriculum-senior-medical-students-based-teamstepps
December 21, 2014 - Study
A surgical simulation curriculum for senior medical students based on TeamSTEPPS.
Citation Text:
Meier AH, Boehler ML, McDowell CM, et al. A surgical simulation curriculum for senior medical students based on TeamSTEPPS. Arch Surg. 2012;147(8):761-6. doi:10.1001/archsurg.2012.1340.…
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psnet.ahrq.gov/issue/wake-hospital-inquiries-impact-staff-and-safety
January 12, 2022 - Commentary
In the wake of hospital inquiries: impact on staff and safety.
Citation Text:
Dunbar JA, Reddy P, Beresford B, et al. In the wake of hospital inquiries: impact on staff and safety. Med J Aust. 2007;186(2):80-3.
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psnet.ahrq.gov/issue/unexpected-intraoperative-patient-death-imperatives-family-and-surgeon-centered-care
August 04, 2021 - Commentary
Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care.
Citation Text:
Taylor D, Hassan MA, Luterman A, et al. Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care. Arch Surg. 2008;143(1):87-92. do…
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psnet.ahrq.gov/issue/use-simulation-healthcare-systems-issues-team-building-task-training-education-and-high
October 03, 2011 - Review
The use of simulation in healthcare: from systems issues, to team building, to task training, to education and high stakes examinations.
Citation Text:
Orledge J, Phillips WJ, Murray B, et al. The use of simulation in healthcare: from systems issues, to team building, to task t…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-starting-practice.pdf
June 02, 2025 - Job Aid: Starting with a Practice
Primary Care Practice Facilitator
Training Series
1
Job Aid: Starting with a Practice
Overview
How you start with a practice can set the tone for your work with the practice. Do your
homework and be well prepared for all of your meetings. Spend time getting to know…
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psnet.ahrq.gov/issue/care-and-outcomes-patients-hospital-stroke
September 18, 2024 - Study
Care and outcomes of patients with in-hospital stroke.
Citation Text:
Saltman AP, Silver FL, Fang J, et al. Care and Outcomes of Patients With In-Hospital Stroke. JAMA Neurol. 2015;72(7):749-55. doi:10.1001/jamaneurol.2015.0284.
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psnet.ahrq.gov/issue/evaluation-parenteral-nutrition-errors-era-drug-shortages
October 02, 2013 - Study
Evaluation of parenteral nutrition errors in an era of drug shortages.
Citation Text:
Storey MA, Weber RJ, Besco K, et al. Evaluation of Parenteral Nutrition Errors in an Era of Drug Shortages. Nutr Clin Pract. 2016;31(2):211-7. doi:10.1177/0884533615608820.
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www.ahrq.gov/hai/cauti-tools/impl-guide/implementation-guide-appendix-m.html
October 01, 2020 - Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Appendix M. Example of a Nurse-Driven Protocol for Catheter Removal
Previous Page Next Page
Table of Contents
Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units…
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www.ahrq.gov/news/newsroom/case-studies/201525.html
September 01, 2015 - AHRQ’s Medical Office Survey Helps Colorado Hospital Provide Better Care
Search All Impact Case Studies
September 2015
Yuma District Hospital and Clinics, a 15-bed hospital with two rural health clinics in northeast Colorado, has used results from an AHRQ-developed patient safety survey, the Medical Office…
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psnet.ahrq.gov/issue/evaluating-handheld-decision-support-device-pediatric-intensive-care-settings
January 18, 2023 - Study
Evaluating a handheld decision support device in pediatric intensive care settings.
Citation Text:
Evaluating a handheld decision support device in pediatric intensive care settings. Reynolds TL, DeLucia PR, Esquibel KA, et al. JAMIA Open. 2019;2:49-61.
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psnet.ahrq.gov/issue/fatal-errors-nitrous-oxide-delivery
March 02, 2011 - Review
Fatal errors in nitrous oxide delivery.
Citation Text:
Herff H, Paal P, Von Goedecke A, et al. Fatal errors in nitrous oxide delivery. Anaesthesia. 2007;62(12):1202-1206. doi:10.1111/j.1365-2044.2007.05193.x.
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psnet.ahrq.gov/issue/simulation-based-clinical-rehearsals-method-improving-patient-safety
September 28, 2022 - Commentary
Simulation-based clinical rehearsals as a method for improving patient safety.
Citation Text:
Arnold J, Cashin M, Olutoye OO. Simulation-Based Clinical Rehearsals as a Method for Improving Patient Safety. JAMA Surg. 2018;153(12):1143-1144. doi:10.1001/jamasurg.2018.3526.
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psnet.ahrq.gov/issue/higher-quality-care-and-patient-safety-associated-better-nicu-work-environments
October 19, 2022 - Study
Higher quality of care and patient safety associated with better NICU work environments.
Citation Text:
Lake ET, Hallowell SG, Kutney-Lee A, et al. Higher Quality of Care and Patient Safety Associated With Better NICU Work Environments. J Nurs Care Qual. 2016;31(1):24-32. doi:10.10…
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psnet.ahrq.gov/issue/identifying-cross-contaminants-and-specimen-mix-ups-surgical-pathology
July 22, 2020 - Review
Identifying cross contaminants and specimen mix-ups in surgical pathology.
Citation Text:
Hunt JL. Identifying cross contaminants and specimen mix-ups in surgical pathology. Adv Anat Pathol. 2008;15(4):211-7. doi:10.1097/PAP.0b013e31817bf596.
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psnet.ahrq.gov/issue/clinical-alarms-improving-efficiency-and-effectiveness
February 22, 2010 - Study
Clinical alarms: improving efficiency and effectiveness.
Citation Text:
Phillips J, Barnsteiner JH. Clinical alarms: improving efficiency and effectiveness. Crit Care Nurs Q. 2005;28(4):317-323.
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psnet.ahrq.gov/issue/medication-safety-primary-care-practice-results-pprnet-quality-improvement-intervention
April 23, 2008 - Study
Medication safety in primary care practice: results from a PPRNet quality improvement intervention.
Citation Text:
Wessell AM, Ornstein SM, Jenkins RG, et al. Medication Safety in Primary Care Practice: results from a PPRNet quality improvement intervention. Am J Med Qual. 2013;2…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/training-tools-material-guide.docx
May 01, 2017 - Overview
Definition of Sustainability and its Importance in Quality Improvement
· Slides 4-8
Linking Sustainability and Spread
· Slides 9-10
Planning Early for Sustainability
· Slides 11-12
Barriers and Solutions to Sustaining Improvements
· Slides 13-17
Steps to Creating and Implementing a Sustainability Plan
· Slides…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/sustainability-tool.docx
May 01, 2017 - AHRQ Safety Program for Ambulatory Surgery
Module 4: Sustainability
Sustainability Tool
Background: This tool can be used to identify sustainability issues in planning and implementing your improvement efforts.
How to use this tool: The Implementation Team leader (or individual designated by the leader) should comple…