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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d6_combo_implementationplan.docx
June 02, 2025 - AHRQ QI Toolkit
Implementation Plan
What is the purpose of this tool? The purpose of the implementation plan is to provide a format in which to:
Define the tasks/actions required to implement each selected best practice.
Develop a communication/training and implementation plan.
Set a timeframe and target dates for the …
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psnet.ahrq.gov/node/49814/psn-pdf
December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation
Mishap
December 1, 2017
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
The Case
A 63-year-old man with a history of coronary…
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psnet.ahrq.gov/node/38224/psn-pdf
February 18, 2011 - Hospital readmissions: physician awareness and
communication practices.
February 18, 2011
Roy CL, Kachalia A, Woolf S, et al. Hospital readmissions: physician awareness and communication
practices. J Gen Intern Med. 2009;24(3):374-80. doi:10.1007/s11606-008-0848-x.
https://psnet.ahrq.gov/issue/hospital-readmission…
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psnet.ahrq.gov/node/843052/psn-pdf
January 25, 2023 - Improving communication from hospital to skilled nursing
facility through standardized hand-off: a quality
improvement project.
January 25, 2023
Baluyot A, McNeill C, Wiers S. Improving communication from hospital to skilled nursing facility through
standardized hand-off: a quality improvement project. Patient Saf…
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psnet.ahrq.gov/node/45763/psn-pdf
December 19, 2017 - Expanded pharmacy technician roles: accepting verbal
prescriptions and communicating prescription transfers.
December 19, 2017
Frost TP, Adams AJ. Expanded pharmacy technician roles: Accepting verbal prescriptions and
communicating prescription transfers. Res Social Adm Pharm. 2017;13(6):1191-1195.
doi:10.1016/j.s…
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psnet.ahrq.gov/node/867092/psn-pdf
November 06, 2024 - Surgical intraoperative handoff initiative: standardizing
operating room communication using SHRIMPS.
November 6, 2024
Stephens WA, Anderson MJ, Levy BE, et al. Surgical intraoperative handoff initiative: standardizing
operating room communication using SHRIMPS. J Am Coll Surg. 2024;239(4):387-393.
doi:10.1097/xcs…
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psnet.ahrq.gov/node/44810/psn-pdf
April 21, 2016 - Provider-to-provider communication during transitions of
care from outpatient to acute care: a systematic review.
April 21, 2016
Luu N-P, Pitts S, Petty BG, et al. Provider-to-Provider Communication during Transitions of Care from
Outpatient to Acute Care: A Systematic Review. J Gen Intern Med. 2016;31(4):417-25.
…
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psnet.ahrq.gov/node/45448/psn-pdf
January 23, 2017 - Accuracy of laboratory data communication on ICU daily
rounds using an electronic health record.
January 23, 2017
Artis KA, Dyer E, Mohan V, et al. Accuracy of Laboratory Data Communication on ICU Daily Rounds Using
an Electronic Health Record. Crit Care Med. 2017;45(2):179-186. doi:10.1097/CCM.0000000000002060.
h…
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psnet.ahrq.gov/node/838913/psn-pdf
October 26, 2022 - Communication during interhospital transfers of
emergency general surgery patients: a qualitative study
of challenges and opportunities.
October 26, 2022
Alagoz E, Saucke M, Arroyo N, et al. Communication during interhospital transfers of emergency general
surgery patients: a qualitative study of challenges and op…
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psnet.ahrq.gov/node/837334/psn-pdf
June 08, 2022 - Safety gaps in medical team communication: closing the
loop on quality improvement efforts in the cardiac
catheterization lab.
June 8, 2022
Doorey AJ, Turi ZG, Lazzara EH, et al. Safety gaps in medical team communication: closing the loop on
quality improvement efforts in the cardiac catheterization lab. Catheter …
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psnet.ahrq.gov/node/42989/psn-pdf
May 28, 2014 - Interactive questioning in critical care during handovers:
a transcript analysis of communication behaviours by
physicians, nurses and nurse practitioners.
May 28, 2014
Rayo MF, Mount-Campbell AF, O'Brien JM, et al. Interactive questioning in critical care during handovers: a
transcript analysis of communication b…
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psnet.ahrq.gov/node/865589/psn-pdf
April 17, 2024 - Why talking is not cheap: adverse events and informal
communication.
April 17, 2024
Montgomery A, Lainidi O, Georganta K. Why talking is not cheap: adverse events and informal
communication. Healthcare (Basel). 2024;12(6):635. doi:10.3390/healthcare12060635.
https://psnet.ahrq.gov/issue/why-talking-not-cheap-adver…
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psnet.ahrq.gov/node/46187/psn-pdf
December 06, 2017 - A randomised controlled trial assessing the efficacy of an
electronic discharge communication tool for preventing
death or hospital readmission.
December 6, 2017
Santana MJ, Holroyd-Leduc J, Southern DA, et al. A randomised controlled trial assessing the efficacy of
an electronic discharge communication tool for p…
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psnet.ahrq.gov/node/856592/psn-pdf
January 01, 2024 - Talking about falls: a qualitative exploration of spoken
communication of patients' fall risks in hospitals and
implications for multifactorial approaches to fall
prevention.
November 29, 2023
McVey L, Alvarado N, Healey F, et al. Talking about falls: a qualitative exploration of spoken
communication of patients’…
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psnet.ahrq.gov/node/38751/psn-pdf
July 08, 2009 - Nurses' role in communication and patient safety.
July 8, 2009
Nadzam DM. Nurses' role in communication and patient safety. J Nurs Care Qual. 2009;24(3):184-188.
doi:10.1097/01.NCQ.0000356905.87452.62.
https://psnet.ahrq.gov/issue/nurses-role-communication-and-patient-safety
This article offers strategies to enhan…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/tool-safe-mgso4.html
July 01, 2023 - Communicate during transitions of care.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
February 01, 2004 - Because of their limited ability to communicate, children may
be unable to indicate whether they are
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_4-situation-monitoring.pptx
July 01, 2023 - 3
Strategies
Individual awareness can become shared understanding through:
Briefs to establish and communicate … Who will accept responsibility for any outstanding tasks and how will they communicate back to the team … Did they communicate relevant insights and changes in the status of the patient to the rest of the team
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psnet.ahrq.gov/node/36899/psn-pdf
April 12, 2011 - The role of communication in paediatric drug safety.
April 12, 2011
Stebbing C, Wong ICK, Kaushal R, et al. The role of communication in paediatric drug safety. Arch Dis
Child. 2007;92(5):440-5.
https://psnet.ahrq.gov/issue/role-communication-paediatric-drug-safety
The authors review the literature on how communic…
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psnet.ahrq.gov/node/41108/psn-pdf
August 02, 2012 - Effective discharge communication in the emergency
department.
August 2, 2012
Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency
department. Ann Emerg Med. 2012;60(2):152-9. doi:10.1016/j.annemergmed.2011.10.023.
https://psnet.ahrq.gov/issue/effective-discharge-communication-…