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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-2.html
March 01, 2022 - Improving Education—A Key to Better Diagnostic Outcomes
Foundations of Diagnosis Education
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Table of Contents
Improving Education—A Key to Better Diagnostic Outcomes
Introduction
Foundations of Diagnosis Education
Current State of Diagnosis Education
Competencies To Im…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/sheridan_screening_overuse.pdf
January 01, 2014 - Understanding and Reducing Overuse of Potentially Harmful Screening Tests
Research Centers for Excellence
in Clinical Preventive Services
Working to get the right services, to the right people, at the right time
Understanding and Reducing Overuse of Potentially Harmful
Screening Tes…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/menu.html
December 01, 2017 - On-Time Quality Improvement Program: On-Time Pressure Ulcer Prevention
Menu of Implementation Strategies
The On-Time Menu of Process Improvement Strategies for using reports is a list of potential ways facility teams may choose to integrate the pressure ulcer prevention reports into clinical practice. A menu …
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/find4.html
December 01, 2012 - Assessing the Health and Welfare of the HCBS Population
Outcome Indicators for the HCBS Population
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Table of Contents
Assessing the Health and Welfare of the HCBS Population
Introduction
HCBS Population
Availability and Use of State Medicaid HCBS
Outcome Indicators for…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/twomorees-slides/Two-More-Es-and-How-to-Spread-Dec-13-2011-508.ppt
January 01, 2011 - Project Report - Lean Sigma
Two More E’s and How to Spread
Learning Objectives
To think ahead about ways to make your investment of time and improvements in BSI rates last forever
To make sure all patients in your institution have access to the same level of safety in their care
Implementation Framework
Al…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Prologue_Keyes_Vol3.pdf
June 02, 2025 - Prologue: The Shift toward Performance and Tools
Prologue
The Shift toward Performance and Tools
Margaret A. Keyes, M.A.
The articles in this volume provide a number of perspectives on performance and tools used to
improve the safe delivery of health care. They include a wide variety of approaches that
…
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psnet.ahrq.gov/issue/exploring-leadership-within-systems-approach-reduce-health-care-associated-infections-scoping
October 29, 2017 - Review
Exploring leadership within a systems approach to reduce health care–associated infections: a scoping review of one work system model.
Citation Text:
Knobloch MJ, Thomas K, Musuuza J, et al. Exploring leadership within a systems approach to reduce health care-associated infections…
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psnet.ahrq.gov/issue/medication-event-huddles-tool-reducing-adverse-drug-events
December 19, 2014 - Commentary
Medication event huddles: a tool for reducing adverse drug events.
Citation Text:
Morvay S, Lewe D, Stewart B, et al. Medication event huddles: a tool for reducing adverse drug events. Jt Comm J Qual Patient Saf. 2014;40(1):39-45.
Copy Citation
Format:
Google S…
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psnet.ahrq.gov/issue/impact-inpatient-electronic-prescribing-system-prescribing-error-causation-qualitative
February 16, 2022 - Study
Impact of an inpatient electronic prescribing system on prescribing error causation: a qualitative evaluation in an English hospital.
Citation Text:
Puaar SJ, Franklin BD. Impact of an inpatient electronic prescribing system on prescribing error causation: a qualitative evaluation …
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psnet.ahrq.gov/issue/association-between-patient-reported-incidents-hospitals-and-estimated-rates-patient-harm
August 13, 2013 - Study
The association between patient-reported incidents in hospitals and estimated rates of patient harm.
Citation Text:
Bjertnaes O, Deilkås ET, Skudal KE, et al. The association between patient-reported incidents in hospitals and estimated rates of patient harm. Int J Qual Health Care…
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psnet.ahrq.gov/issue/empowerment-failure-how-shortcomings-physician-communication-unwittingly-undermine-patient
January 17, 2019 - Study
Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy.
Citation Text:
Ubel PA, Scherr KA, Fagerlin A. Empowerment Failure: How Shortcomings in Physician Communication Unwittingly Undermine Patient Autonomy. Am J Bioeth. 2017;17(11):…
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psnet.ahrq.gov/issue/first-us-study-nurses-evidence-based-practice-competencies-indicates-major-deficits-threaten
July 14, 2021 - Study
Classic
The first U.S. study on nurses' evidence-based practice competencies indicates major deficits that threaten healthcare quality, safety, and patient outcomes.
Citation Text:
Melnyk BM, Gallagher-Ford L, Zellefrow C, et al. The First U.S. Study on Nu…
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psnet.ahrq.gov/issue/residents-perspectives-acgme-regulation-supervision-and-duty-hours-national-survey
December 02, 2014 - Study
Residents' perspectives on ACGME regulation of supervision and duty hours—a national survey.
Citation Text:
Drolet BC, Spalluto LB, Fischer SA. Residents' perspectives on ACGME regulation of supervision and duty hours--a national survey. N Engl J Med. 2010;363(23):e34. doi:10.105…
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psnet.ahrq.gov/issue/family-medicine-presence-labor-and-delivery-effect-safety-culture-and-cesarean-delivery
May 24, 2023 - Study
Family medicine presence on labor and delivery: effect on safety culture and cesarean delivery.
Citation Text:
VanGompel EW, Singh L, Carlock F, et al. Family medicine presence on labor and delivery: effect on safety culture and cesarean delivery. Ann Fam Med. 2024;22(5):375-382. d…
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psnet.ahrq.gov/issue/complications-and-death-start-new-academic-year-there-july-phenomenon
February 13, 2008 - Study
Complications and death at the start of the new academic year: is there a July phenomenon?
Citation Text:
Inaba K, Recinos G, Teixeira PGR, et al. Complications and death at the start of the new academic year: is there a July phenomenon? J Trauma. 2010;68(1):19-22. doi:10.1097/TA.…
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psnet.ahrq.gov/issue/interprofessional-handover-and-patient-safety-anaesthesia-observational-study-handovers
April 18, 2011 - Study
Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room.
Citation Text:
Smith AF, Pope C, Goodwin D, et al. Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery r…
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psnet.ahrq.gov/issue/safety-and-communication-operating-room-safety-questionnaire-after-implementation-blood-borne
September 23, 2020 - Study
Safety and communication in the operating room: a safety questionnaire after the implementation of a blood-borne pathogen exposure checkpoint in the surgical safety checklist preprocedure time-out.
Citation Text:
Kane P, Marley R, Daney B, et al. Safety and Communication in the Ope…
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psnet.ahrq.gov/issue/work-related-critical-incidents-hospital-based-health-care-providers-and-risk-post-traumatic
April 12, 2023 - Study
Work-related critical incidents in hospital-based health care providers and the risk of post-traumatic stress symptoms, anxiety, and depression: a meta-analysis.
Citation Text:
de Boer J, Lok A, Verlaat EV't, et al. Work-related critical incidents in hospital-based health care pr…
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psnet.ahrq.gov/issue/impact-interruptions-duration-nursing-interventions-direct-observation-study-academic
February 13, 2019 - Study
The impact of interruptions on the duration of nursing interventions: a direct observation study in an academic emergency department.
Citation Text:
Cole G, Stefanus D, Gardner H, et al. The impact of interruptions on the duration of nursing interventions: a direct observation stud…
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psnet.ahrq.gov/issue/assessment-automating-safety-surveillance-electronic-health-records-analysis-quality-and
October 17, 2018 - Study
Assessment of automating safety surveillance from electronic health records: analysis for the quality and safety review system.
Citation Text:
Fong A, Adams KT, Samarth A, et al. Assessment of Automating Safety Surveillance From Electronic Health Records: Analysis for the Quality a…