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psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
March 01, 2011 - So there is a handoff occurring at discharge, and I often think just like you would communicate and sign
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psnet.ahrq.gov/issue/disclosing-medical-errors-guide-effective-explanation-and-apology
October 26, 2007 - Book/Report
Disclosing Medical Errors: A Guide to an Effective Explanation and Apology.
Citation Text:
Disclosing Medical Errors: A Guide to an Effective Explanation and Apology. Oakbrook Terrace IL: Joint Commission Resources; 2007. ISBN 9781599400211.
Copy Citation
…
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psnet.ahrq.gov/node/40898/psn-pdf
February 06, 2012 - Creating a web-based incident analysis and
communication system.
February 6, 2012
Marsal S, Heffner JE. Creating a web-based incident analysis and communication system. J Hosp Med.
2012;7(2):142-7. doi:10.1002/jhm.956.
https://psnet.ahrq.gov/issue/creating-web-based-incident-analysis-and-communication-system
This…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/ps-research-summary-pfe.pdf
April 30, 2025 - Graphics
2006-2009
$100,000
Final Report
Purpose: To develop novel interactive computer graphics to communicate … $634,959
Final Report
Purpose: To assess the healthcare access and quality of deaf people who primarily
communicate
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www.ahrq.gov/hai/cusp/modules/apply/alt-text.html
March 01, 2013 - Apply Module Slide Presentation Text Descriptions
Slide Number and Title
Slide Content
Content for Alternative Text (Illustration)
Slide 1
Cover Slide
(CUSP Toolkit logo)
The “Apply CUSP” module of the CUSP Toolkit. The CUSP toolkit is a modular approach to patient safety, and modules pr…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/smith2slides.pdf
June 02, 2025 - Development of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture: Slide Presentation
12
12
Development of the AHRQ
Ambulatory Surgery Center
Survey on Patient Safety Culture
Scott Smith, PhD
Senior Study Director
13
13
What is Patient Safety Culture?
“The way we do things around he…
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cdsic.ahrq.gov/sites/default/files/2025-03/SRF%20Standards%20for%20Patient%20Preferences.pdf
January 01, 2025 - e.g., as they come in or batched), and whether they
want to use tools such as the patient portal to communicate … and priorities for care using existing HL7
FHIR standards in the event that a patient is unable to
communicate … that health systems tend to
capture some of this information in terms of patient-preferred ways to communicate
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psnet.ahrq.gov/issue/how-communication-among-members-health-care-team-affects-maternal-morbidity-and-mortality
November 12, 2014 - Commentary
How communication among members of the health care team affects maternal morbidity and mortality.
Citation Text:
Brennan RA, Keohane CA. How Communication Among Members of the Health Care Team Affects Maternal Morbidity and Mortality. J Obstet Gynecol Neonatal Nurs. 2016;45(6)…
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psnet.ahrq.gov/issue/barriers-and-facilitators-communicating-nursing-errors-long-term-care-settings
March 27, 2018 - Study
Barriers and facilitators to communicating nursing errors in long-term care settings.
Citation Text:
Wagner LM, Damianakis T, Pho L, et al. Barriers and facilitators to communicating nursing errors in long-term care settings. J Patient Saf. 2013;9(1):1-7. doi:10.1097/PTS.0b013e31…
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psnet.ahrq.gov/issue/evaluation-information-transfer-through-continuum-surgical-care-feasibility-study
December 21, 2014 - Study
An evaluation of information transfer through the continuum of surgical care: a feasibility study.
Citation Text:
Nagpal K, Vats A, Ahmed K, et al. An evaluation of information transfer through the continuum of surgical care: a feasibility study. Ann Surg. 2010;252(2):402-7. doi:1…
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psnet.ahrq.gov/issue/do-safety-checklists-improve-teamwork-and-communication-operating-room-systematic-review
January 19, 2016 - Review
Do safety checklists improve teamwork and communication in the operating room? A systematic review.
Citation Text:
Russ S, Rout S, Sevdalis N, et al. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg. 2013;258(6):856-71. …
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psnet.ahrq.gov/issue/use-briefings-and-debriefings-tool-improving-team-work-efficiency-and-communication-operating
September 07, 2011 - Study
Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre.
Citation Text:
Bethune R, Sasirekha G, Sahu A, et al. Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the…
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psnet.ahrq.gov/issue/effects-interdisciplinary-collaboration-hospitals-medication-errors-integrative-review
June 16, 2021 - Review
Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review.
Citation Text:
Manias E. Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. Expert Opin Drug Saf. 2018;17(3):259-275. doi:10.1080/…
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www.ahrq.gov/news/newsroom/case-studies/201903.html
April 01, 2019 - Johns Hopkins Children’s Center Uses AHRQ-Funded I-PASS Tool to Boost Patient Safety
Search All Impact Case Studies
April 2019
Pediatric residents at Johns Hopkins Children’s Center in Baltimore, MD, changed the way they handed off patients between shift changes by closely adhering—sometimes by as much as …
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psnet.ahrq.gov/node/40257/psn-pdf
March 02, 2011 - Interventions to improve teamwork and communications
among healthcare staff.
March 2, 2011
McCulloch P, Rathbone J, Catchpole K. Interventions to improve teamwork and communications among
healthcare staff. Br J Surg. 2011;98(4):469-79. doi:10.1002/bjs.7434.
https://psnet.ahrq.gov/issue/interventions-improve-teamwo…
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psnet.ahrq.gov/node/38808/psn-pdf
January 01, 2013 - Patient Safety Organizations: a new paradigm in quality
management and communication systems in healthcare.
July 22, 2009
Dotan DB. Patient safety organizations. J Clin Engineer. 2013;34(3):142-146.
doi:10.1097/jce.0b013e3181aae4b2.
https://psnet.ahrq.gov/issue/patient-safety-organizations-new-paradigm-quality-man…
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psnet.ahrq.gov/node/34603/psn-pdf
September 29, 2017 - Disclosure of unanticipated events: creating an effective
patient communication policy (part 2 of 3).
September 29, 2017
American Society of Healthcare Risk Management; ASHRM
https://psnet.ahrq.gov/issue/disclosure-unanticipated-events-creating-effective-patient-communication-
policy-part-2-3
The process for craf…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-241-bmi-communication-section-6-tables-3-4.pdf
June 02, 2025 - CHIPRA 241: Section 6, Tables 3 and 4
Table 3: Agreement and Kappa Statistics for Inter-Rater Reliability
Variable Description
Records
Reviewed
For IRR (N)
N Agreed
(%)
Kappa
Statistic
Documentation of communication of weight status 20 18 (90) 0.899
Documentation of height 20 20 (100) 1
Docum…
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psnet.ahrq.gov/node/49651/psn-pdf
May 01, 2012 - For example, by 12 months, residents should be able to effectively communicate with other
caregivers
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psnet.ahrq.gov/node/44542/psn-pdf
December 22, 2018 - The prevalence of medical error related to end-of-life
communication in Canadian hospitals: results of a
multicentre observational study.
December 22, 2018
Heyland DK, Ilan R, Jiang X, et al. The prevalence of medical error related to end-of-life communication in
Canadian hospitals: results of a multicentre observ…