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psnet.ahrq.gov/issue/teaching-medication-reconciliation-through-simulation-patient-safety-initiative-second-year
May 04, 2010 - Commentary
Teaching medication reconciliation through simulation: a patient safety initiative for second year medical students.
Citation Text:
Lindquist LA, Gleason KM, McDaniel MR, et al. Teaching medication reconciliation through simulation: a patient safety initiative for second yea…
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psnet.ahrq.gov/issue/effect-bedrails-falls-and-injury-systematic-review-clinical-studies
March 15, 2016 - Review
The effect of bedrails on falls and injury: a systematic review of clinical studies.
Citation Text:
Healey F, Oliver D, Milne A, et al. The effect of bedrails on falls and injury: a systematic review of clinical studies. Age Ageing. 2008;37(4):368-78. doi:10.1093/ageing/afn112. …
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psnet.ahrq.gov/issue/teaching-medical-error-apologies-development-multi-component-intervention
August 04, 2021 - Study
Teaching medical error apologies: development of a multi-component intervention.
Citation Text:
Gillies RA, Speers SH, Young SE, et al. Teaching medical error apologies: development of a multi-component intervention. Fam Med. 2011;43(6):400-6.
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psnet.ahrq.gov/issue/errors-and-omissions-anesthesia-pilot-study-using-pilots-checklist
September 23, 2020 - Study
Errors and omissions in anesthesia: a pilot study using a pilot's checklist.
Citation Text:
Hart EM, Owen H. Errors and omissions in anesthesia: a pilot study using a pilot's checklist. Anesth Analg. 2005;101(1):246-50, table of contents.
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psnet.ahrq.gov/issue/health-literacy-medication-errors-and-health-outcomes-there-relationship
January 02, 2008 - Review
Health literacy, medication errors, and health outcomes: is there a relationship?
Citation Text:
Warner A, Menachemi N, Brooks RG. Health Literacy, Medication Errors, and Health Outcomes: Is There a Relationship? Hosp Pharm. 2010;41(6):542-551. doi:10.1310/hpj4106-538.
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psnet.ahrq.gov/issue/insensible-losses-when-medical-community-forgets-family
January 17, 2024 - Commentary
Insensible losses: when the medical community forgets the family.
Citation Text:
Elias P. Insensible losses: when the medical community forgets the family. Health Aff (Millwood). 2015;34(4):707-710. doi:10.1377/hlthaff.2014.0536.
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-166-fecc-tables-13-14.pdf
June 02, 2025 - Section 7.B, Tables 13 and 14
Indicator Indicator Does not live Lives in
ID in MSA MSA
(N=217) (n=625)
Care Coordination Services
Has care coordinator FECC-1 73.5 69.8
Access to care coordinator FECC-2 97.5 96.1
Care coordinator helped to obtain
community services
FECC-3
…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-166-fecc-tables-15-16.pdf
June 02, 2025 - Section 7.E, Tables 15 and 16
Indicator Indicator
ID
English
proficient
(n=1094)
LEP
(n=154)
Care Coordination Services
Has care coordinator
Access to care coordinator
Care coordinator helped to obtain community
services
Care coordinator contact in the last 3 months
Care coo…
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psnet.ahrq.gov/issue/reducing-surgical-specimen-errors-through-multidisciplinary-quality-improvement
July 28, 2021 - Study
Reducing surgical specimen errors through multidisciplinary quality improvement.
Citation Text:
Holstine JB, Samora JB. Reducing surgical specimen errors through multidisciplinary quality improvement. Jt Comm J Qual Patient Saf. 2021;47(9):563-571. doi:10.1016/j.jcjq.2021.04.003.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects_revised.docx
April 01, 2022 - CLABSI Learning From Defects Tool
Learn From Defects Tool Worksheet:
Central Line-Associated Bloodstream Infection (CLABSI)
This worksheet is designed to be used near the bedside and is the shortened version of the CLABSI Event Report Tool: Data for Event Analysis. This worksheet will help your team learn what happ…
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psnet.ahrq.gov/issue/clinical-handovers-between-prehospital-and-hospital-staff-literature-review
March 23, 2022 - Review
Clinical handovers between prehospital and hospital staff: literature review.
Citation Text:
Wood K, Crouch R, Rowland E, et al. Clinical handovers between prehospital and hospital staff: literature review. Emerg Med J. 2015;32(7):577-581. doi:10.1136/emermed-2013-203165.
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psnet.ahrq.gov/issue/medication-injection-safety-knowledge-and-practices-among-anesthesiologists-new-york-state
August 25, 2021 - Study
Medication injection safety knowledge and practices among anesthesiologists: New York State, 2011.
Citation Text:
Gounder P, Beers R, Bornschlegel K, et al. Medication injection safety knowledge and practices among anesthesiologists: New York State, 2011. J Clin Anesth. 2013;25(7)…
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psnet.ahrq.gov/issue/competence-and-certification-registered-nurses-and-safety-patients-intensive-care-units
May 01, 2006 - Study
Competence and certification of registered nurses and safety of patients in intensive care units.
Citation Text:
Kendall-Gallagher D, Blegen MA. Competence and certification of registered nurses and safety of patients in intensive care units. Am J Crit Care. 2009;18(2):106-113; q…
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psnet.ahrq.gov/issue/lessons-learned-basic-evidence-based-advice-preventing-medication-errors-children
December 22, 2008 - Commentary
Lessons learned: basic evidence-based advice for preventing medication errors in children.
Citation Text:
Thomas DO. Lessons learned: basic evidence-based advice for preventing medication errors in children. Journal of emergency nursing: JEN : official publication of the Eme…
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psnet.ahrq.gov/issue/getting-underuse-interpreters-resident-physicians
February 21, 2018 - Study
Getting by: underuse of interpreters by resident physicians.
Citation Text:
Diamond LC, Schenker Y, Curry LA, et al. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med. 2009;24(2):256-62. doi:10.1007/s11606-008-0875-7.
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psnet.ahrq.gov/issue/system-safety-approach-assessing-risks-sepsis-treatment-process
February 03, 2021 - Study
A system safety approach to assessing risks in the sepsis treatment process.
Citation Text:
Kaya GK. A system safety approach to assessing risks in the sepsis treatment process. Appl Ergon. 2021;94:103408. doi:10.1016/j.apergo.2021.103408.
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DOI Go…
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psnet.ahrq.gov/issue/omitted-and-unjustified-medications-discharge-summary
May 18, 2022 - Study
Omitted and unjustified medications in the discharge summary.
Citation Text:
Perren A, Previsdomini M, Cerutti B, et al. Omitted and unjustified medications in the discharge summary. Qual Saf Health Care. 2009;18(3):205-8. doi:10.1136/qshc.2007.024588.
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psnet.ahrq.gov/issue/right-medication-right-dose-right-patient-right-time-and-right-route-how-do-we-select-right
March 02, 2016 - Commentary
Right medication, right dose, right patient, right time, and right route: how do we select the right patient-controlled analgesia (PCA) device?
Citation Text:
Ladak SSJ, Chan VWS, Easty T, et al. Right medication, right dose, right patient, right time, and right route: how d…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects-revised.docx
April 01, 2022 - CAUTI Learning From Defects Tool
Learn From Defects Tool Worksheet:
Catheter-Associated Urinary Tract Infection (CAUTI)
This worksheet is designed to be used near the bedside and is the shortened version of the CAUTI Event Report Tool: Data for Event Analysis. This worksheet will help your team learn what happened,…
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psnet.ahrq.gov/issue/clinical-information-transfer-and-medication-reconciliation-patients-transferred-pediatric
September 28, 2010 - Study
Clinical information transfer and medication reconciliation in patients transferred from the pediatric intensive care unit.
Citation Text:
Grant MJC, Larsen GY. Clinical Information Transfer and Medication Reconciliation in Patients Transferred from the Pediatric Intensive Care U…