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psnet.ahrq.gov/node/855437/psn-pdf
November 15, 2023 - Advancing Diagnostic Excellence for Maternal Health
Care: Proceedings of a Workshop–in Brief.
November 15, 2023
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2023. ISBN: 9780309711937.
https://psnet.ahrq.gov/issue/advancing-diagnostic-excellence-maternal-h…
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psnet.ahrq.gov/node/42539/psn-pdf
September 27, 2016 - Causes of medication administration errors in hospitals: a
systematic review of quantitative and qualitative
evidence.
September 27, 2016
Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a
systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(1…
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psnet.ahrq.gov/node/73452/psn-pdf
June 30, 2021 - Administration of concentrated potassium chloride for
injection during a code: still deadly!
June 30, 2021
ISMP Medication Safety Alert! Acute care edition. June 3, 2021; 26(11): 1-5.
https://psnet.ahrq.gov/issue/administration-concentrated-potassium-chloride-injection-during-code-still-
deadly
Concentrated …
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psnet.ahrq.gov/node/853436/psn-pdf
September 13, 2023 - Long-term sustainability and adaptation of I-PASS
handovers.
September 13, 2023
Ryan SL, Logan M, Liu X, et al. Long-term sustainability and adaptation of I-PASS handovers. Jt Comm J
Qual Patient Saf. 2023;19(12):689-697. doi:10.1016/j.jcjq.2023.07.007.
https://psnet.ahrq.gov/issue/long-term-sustainability-and-ada…
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psnet.ahrq.gov/node/852286/psn-pdf
August 09, 2023 - Guidelines on Human Factors in Critical Situations 2023.
August 9, 2023
Bijok B, Jaulin F, Picard J, et al. Guidelines on human factors in critical situations 2023. Anaesth Crit Care
Pain Med. 2023;42(4):101262. doi:10.1016/j.accpm.2023.101262.
https://psnet.ahrq.gov/issue/guidelines-human-factors-critical-situatio…
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www.ahrq.gov/hai/cusp/modules/apply/index.html
July 01, 2018 - Apply CUSP
The Apply CUSP module of the CUSP Toolkit introduces Just Culture principles, which emphasize shared accountability and attitudes towards risk. This module also summarizes the concepts and activities of the other six modules in the CUSP Toolkit, including TeamSTEPPS communication tools.
This module…
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psnet.ahrq.gov/node/73365/psn-pdf
June 09, 2021 - Enhancing psychological safety in mental health services.
June 9, 2021
Hunt DF, Bailey J, Lennox BR, et al. Enhancing psychological safety in mental health services. Int J Ment
Health Syst. 2021;15(1):33. doi:10.1186/s13033-021-00439-1.
https://psnet.ahrq.gov/issue/enhancing-psychological-safety-mental-health-servi…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2019_hpchartbook_infographic.pdf
January 01, 2019 - 2019 CAHPS Health Plan Survey Database Chartbook Executive Summary
CAHPS® 2019 Health Plan Survey Database
This overview of resu lts summarizes how health plan enrollees across all
populations rate their health plan based on the 2019 Consumer Assessment of
Healthcare Providers and Systems (CAHPS®) Health Plan S…
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www.ahrq.gov/cahps/surveys-guidance/outpatient-mental-health/about/survey-measures.html
October 01, 2024 - CAHPS Outpatient Mental Health Survey Measures
For more information: Patient Experience Measures from the Outpatient Mental Health Survey (PDF, 219 KB) Getting Appointments for Prescription Medicines Q3 Difficulty making appointments for prescription medicine Getting Mental Health Counseling Q10 Difficulty fi…
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psnet.ahrq.gov/node/50590/psn-pdf
January 01, 2020 - Patient and family engagement as a potential approach
for improving patient safety: a systematic review.
October 30, 2019
Park M, Giap T-T-T. Patient and family engagement as a potential approach for improving patient safety: A
systematic review. J Adv Nurs. 2020;76(1):62-80. doi:10.1111/jan.14227.
https://psnet.a…
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psnet.ahrq.gov/node/44002/psn-pdf
March 25, 2015 - Preventing medication errors in transitions of care: a
patient case approach.
March 25, 2015
Johnson A, Guirguis E, Grace Y. Preventing medication errors in transitions of care: A patient case
approach. J Am Pharm Assoc (2003). 2015;55(2):e264-276. doi:10.1331/JAPhA.2015.15509.
https://psnet.ahrq.gov/issue/prevent…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/defects.html
May 01, 2017 - Learn From Defects - Implementation Guide
Purpose: To identify the types of systems that contributed to the defect (an event or situation that you do not want to happen again) and to plan the followup steps needed to improve safety.
Who should use this tool? Senior leaders, facility team leads, …
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psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - comprehend the information presented, understand the risks, benefits, and consequences of their decisions, communicate
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - Her agitation and hallucinations impaired her ability to communicate or answer review of systems questions
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/017-contact-precautions-webinar-slides-notes.docx
October 01, 2024 - Communication, Signage, and Flagging
SAY:
For contact precautions to be effective, there needs to be a way to communicate
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-166-fecc-figure-1-tables-1-5.pdf
January 01, 2011 - Institute of
Medicine (IOM)
20013
All patients Recommends that “clinicians
and patients should
communicate
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017831-mertens-final-report-2012.pdf
January 01, 2012 - Improving Pediatric Cancer Survivorship Care through SurvivorLink - Final Report
Grant Final Report
Grant ID: R18HS017831
Improving Pediatric Cancer Survivorship Care through
SurvivorLink
Inclusive project dates: 09/30/08 - 09/29/11
Principal Investigator:
Ann C Mertens, PhD
Team members:
Lillian Meac…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-StJacques_105.pdf
March 29, 2008 - Improving Perioperative Patient Safety Through the Use of Information Technology
1
Improving Perioperative Patient Safety
Through the Use of Information Technology
Paul J. St. Jacques, MD; Michael N. Minear
Abstract
The perioperative care process is a unique and challenging environment. Perioperative …
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www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/womenh-slides.html
March 01, 2020 - Chartbook on Women's Health Care: Slide Presentation
2014 National Healthcare Quality & Disparities Report
Contents
Introduction
Summary Tables
Access to Health Care
Patient Safety
Person-and Family-Centered Care
Communication and Care Coordination
Effective Treatment of Leading Causes of Morbid…
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psnet.ahrq.gov/node/33576/psn-pdf
December 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient
Surgery
December 15, 2024
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editoria…