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psnet.ahrq.gov/issue/comparative-analysis-incident-reporting-lag-times-academic-medical-centres-japan-and-usa
March 23, 2011 - Study
A comparative analysis of incident reporting lag times in academic medical centres in Japan and the USA.
Citation Text:
Regenbogen SE, Hirose M, Imanaka Y, et al. A comparative analysis of incident reporting lag times in academic medical centres in Japan and the USA. Qual Saf Hea…
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psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and
July 23, 2010 - Commentary
Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills.
Citation Text:
Fassett WE. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects …
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psnet.ahrq.gov/issue/reflection-adverse-event-disclosure-postsurgical-hospital-context
August 20, 2018 - Commentary
Reflection on adverse event disclosure in the postsurgical hospital context.
Citation Text:
Roberts F, Gettings P, Torbeck L, et al. Reflection on adverse event disclosure in the postsurgical hospital context. J Surg Educ. 2015;72(4):767-70. doi:10.1016/j.jsurg.2014.12.016.
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psnet.ahrq.gov/issue/interhospital-transfer-handoff-practices-among-us-tertiary-care-centers-descriptive-survey
November 02, 2016 - Study
Interhospital transfer handoff practices among US tertiary care centers: a descriptive survey.
Citation Text:
Herrigel DJ, Carroll M, Fanning C, et al. Interhospital transfer handoff practices among US tertiary care centers: A descriptive survey. J Hosp Med. 2016;11(6):413-7. doi:1…
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psnet.ahrq.gov/issue/improving-situation-awareness-advance-patient-outcomes-systematic-literature-review
January 16, 2010 - Review
Improving situation awareness to advance patient outcomes: a systematic literature review.
Citation Text:
Alqarrain Y, Roudsari A, Courtney KL, et al. Improving situation awareness to advance patient outcomes: a systematic literature review. Comput Inform Nurs. 2024;42(4):277-288.…
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psnet.ahrq.gov/issue/epidemiology-adverse-events-air-medical-transport
July 03, 2014 - Study
Epidemiology of adverse events in air medical transport.
Citation Text:
MacDonald RD, Banks BA, Morrison M. Epidemiology of adverse events in air medical transport. Acad Emerg Med. 2008;15(10):923-931. doi:10.1111/j.1553-2712.2008.00241.x.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/dailygoals.docx
January 01, 2003 - Daily Goals Checklist
Problem statement: Clear communication among health care providers is paramount. Communication failures lead to patient harm, increased length of stay, provider dissatisfaction, and staff turnover. Effective communication is particularly important in the unit if complicated care plans are to be …
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psnet.ahrq.gov/issue/error-omission-simple-checklist-approach-improving-operating-room-safety
August 03, 2022 - Commentary
The error of omission: a simple checklist approach for improving operating room safety.
Citation Text:
Rosenfield LK, Chang DS. The error of omission: a simple checklist approach for improving operating room safety. Plast Reconstr Surg. 2009;123(1):399-402. doi:10.1097/PRS.0…
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www.ahrq.gov/teamstepps-program/evidence-base/research.html
June 01, 2023 - TeamSTEPPS Research and Tools
Agency for Healthcare Research and Quality. (2006). TeamSTEPPS™ Guide to Action: Creating a Safety Net for your Healthcare Organization . AHRQ Publication No. 06-0020-4.
Castner, J. (2012). Validity and reliability of the Brief TeamSTEPPS Teamwork Perceptions Questionnaire. Jo…
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psnet.ahrq.gov/node/49497/psn-pdf
December 01, 2005 - One
should endeavor to develop an implementation plan that is “win-win” and communicate that effectively—ie
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digital.ahrq.gov/sites/default/files/docs/citation/r18hs022746-neale-final-report-2014.pdf
January 01, 2014 - patients in the safety net clinics logged into the EHR web portal to access their records
or communicate … Use secure electronic messaging to communicate with patients on
relevant health information, specifically … when more “than 10% of patients use
secure electronic messaging to communicate with their providers … patients’ utilization of a secure Web portal (the EpicCare EHR) to
view their medical records and communicate … relevant educational information in the
patient’s preferred language, and the opportunity to communicate
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/teamwork-ptsafety-norms-slides.pdf
August 01, 2025 - Improving Safety Using Teamwork and Patient Safety Norms
Creating and Maintaining a Culture of Safety Series
(Session 2)
Improving Safety Using Teamwork and Patient Safety Norms
NATIONAL WEBINAR SERIES
March 18, 2025
Housekeeping Instructions
• This webinar will be recorded and available for viewing on the NAA…
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digital.ahrq.gov/organization/utah-health-information-network
January 01, 2023 - Utah Health Information Network
Utah Health Information Network (UHIN) HealthInsight Return on Investment Worksheet: Document Processing
Description
This is a questionnaire designed to be completed by administrators across a health care system. The tool includes questions to a…
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psnet.ahrq.gov/node/47622/psn-pdf
April 24, 2019 - Consumer-directed technologies to improve medication
management and safety.
April 24, 2019
Andrade AQ, Roughead EE. Consumer-directed technologies to improve medication management and
safety. Med J Aust. 2019;210(suppl 6):S24-S27. doi:10.5694/mja2.50029.
https://psnet.ahrq.gov/issue/consumer-directed-technologies-…
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www.ahrq.gov/patient-safety/reports/engage/strategies.html
April 01, 2018 - Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
Evidence-Based Strategies To Engage Patients and Families To Improve Patient Safety
This Guide is composed of four evidence-based strategies that promote meaningful engagement with patients and families in ways that …
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psnet.ahrq.gov/node/851191/psn-pdf
July 05, 2023 - Disclosing medical errors: prioritising the needs of
patients and families.
July 5, 2023
Gallagher TH, Hemmelgarn C, Benjamin EM. Disclosing medical errors: prioritising the needs of patients
and families. BMJ Qual Saf. 2023;32(10):557-561. doi:10.1136/bmjqs-2022-015880.
https://psnet.ahrq.gov/issue/disclosing-med…
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psnet.ahrq.gov/node/43760/psn-pdf
March 20, 2015 - Pending studies at hospital discharge: a pre-post analysis
of an electronic medical record tool to improve
communication at hospital discharge.
March 20, 2015
Kantor MA, Evans KH, Shieh L. Pending studies at hospital discharge: a pre-post analysis of an electronic
medical record tool to improve communication at ho…
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psnet.ahrq.gov/node/853978/psn-pdf
September 27, 2023 - Fragmented: A Doctor's Quest to Piece Together
American Health Care.
September 27, 2023
Yurkiewicz I. New York, NY: WW Norton & Company, Inc; 2023. ISBN: 9780393881196.
https://psnet.ahrq.gov/issue/doctors-quest-piece-together-american-health-care
Disjointed health care processes contribute to missed test resu…
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psnet.ahrq.gov/node/45377/psn-pdf
October 27, 2016 - Inpatient notes: reducing diagnostic error—a new horizon
of opportunities for hospital medicine.
October 27, 2016
Singh H, Zwaan L. Web Exclusives. Annals for Hospitalists Inpatient Notes - Reducing Diagnostic Error-A
New Horizon of Opportunities for Hospital Medicine. Ann Intern Med. 2016;165(8):HO2-HO4.
doi:10.7…
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psnet.ahrq.gov/node/42922/psn-pdf
April 12, 2014 - Successful implementation of standardized
multidisciplinary bedside rounds, including daily goals, in
a pediatric ICU.
April 12, 2014
Seigel J, Whalen L, Burgess E, et al. Successful implementation of standardized multidisciplinary bedside
rounds, including daily goals, in a pediatric ICU. Jt Comm J Qual Patient S…