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psnet.ahrq.gov/node/33729/psn-pdf
May 01, 2012 - The Emergence of the Trigger Tool as the Premier
Measurement Strategy for Patient Safety
May 1, 2012
Sharek PJ. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety.
PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-pa…
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www.ahrq.gov/sites/default/files/2025-03/newman-toker-report.pdf
January 01, 2025 - Final Progress Report: A Multiyear Grant To Support the Diagnostic Error in Medicine (DEM) Annual Conference
FINAL PROGRESS REPORT TITLE PAGE (R13HS019252, PI Newman-Toker)
Title: A Multiyear Grant to Support the Diagnostic Error in Medicine (DEM) Annual Conference
Principal Investigator: David E. Newman-Toker
Tea…
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psnet.ahrq.gov/node/853773/psn-pdf
September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side.
September 27, 2023
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
The Case
A first-year orthopedic surgery resident was consulted…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/node/49712/psn-pdf
June 01, 2014 - May I Have Another?—Medication Error
June 1, 2014
Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
The Case
A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a
pharmacology-tra…
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www.ahrq.gov/ncepcr/tools/confid-report/physfeedback.html
February 01, 2016 - Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance
Part One: Physician Feedback Report Fundamentals
Previous Page Next Page
Table of Contents
Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance
Foreword
Introduction
Part One: P…
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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a
Patient Admitted for Leg Fractures
March 27, 2024
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module6/sustainability-slides-spanish.pptx
January 01, 2005 - Módulo 6: Sostenibilidad
Módulo 6: Sostenibilidad
Programa de seguridad de la AHRQ para cuidados a largo plazo: HAI/CAUTI
Kit de herramientas de seguridad para cuidados a largo plazo
AHRQ Pub. No. 16(17)-0003-03-EF
Marzo de 2017
Sostenibilidad | ‹#›
1
Objetivos
Definir la sostenibilidad y comprender la importanc…
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www.ahrq.gov/sites/default/files/2024-02/whitney-report.pdf
January 01, 2024 - Final Progress Report: A new approach to the allocation of decisional authority
FINAL REPORT
A new approach to the allocation of decisional authority
Simon Whitney, MD, JD, Principal Investigator
Team members
Robert Volk, PhD, vice chair for research, Baylor College of Medicine, Department of
Family …
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www.ahrq.gov/sites/default/files/2024-01/greenfield-report.pdf
January 01, 2024 - Final Report: Collaborative Clinical Culture and Quality of Care
Title of Project: Collaborative Clinical Culture and Quality of Care
Principal Investigator and Team Members
Sheldon Greenfield, Principal Investigator
Sherrie H. Kaplan, Co-Principal Investigator
Douglas Roblin, Co-Principal Investigator
Norma Te…
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psnet.ahrq.gov/node/33663/psn-pdf
September 15, 2008 - Implementing a Patient Safety Program at a Large
National Health System
January 1, 2008
Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
Perspectiv…
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psnet.ahrq.gov/node/843151/psn-pdf
February 01, 2023 - Patient Safety Concerns and the LGBTQ+ Population
February 1, 2023
Wesley C, Van CM, Mossburg S. Patient Safety Concerns and the LGBTQ+ Population. PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/patient-safety-concerns-and-lgbtq-population
Challenges to Obtaining Needed Patient-Centered and Safe Health…
-
psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered
Nurses and Paramedics To Provide Home Visits to
Recently Discharged Patients at Highest Risk for Hospital
Readmission
April 7, 2022
https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-
paramedics-provide-home
Sum…
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www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily4.html
July 01, 2018 - Guide to Patient and Family Engagement
Summary and Discussion
Previous Page Next Page
Table of Contents
Guide to Patient and Family Engagement
Executive Summary
Introduction
Methods
Findings
Implications for the Guide
Summary and Discussion
Next Steps
References
Appendix A: Draft K…
-
psnet.ahrq.gov/node/49645/psn-pdf
February 01, 2012 - E-prescribing: E for error?
February 1, 2012
Ashton EW. E-prescribing: E for error? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/e-prescribing-e-error
Case Objectives
Define e-prescribing.
Describe ways in which e-prescribing can reduce health care costs.
State how commonly prescription errors occur wit…
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psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - The Wrong Shot: Error Disclosure
June 1, 2004
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
Case Objectives
Describe the rationale for disclosing harmful errors to patients.
Describe the specific information that patie…
-
psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx
Spotlight
Challenging Case of Multiple Suicide Attempts in a
Complex Patient with Psychiatric Comorbidities
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…
-
psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - A Weighty Mistake
March 1, 2013
Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/weighty-mistake
Case Objectives
Understand factors associated with weight-based dosing medication errors in pediatric populations.
Describe how adoption of computerized provider order entry (CPOE) s…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/gastric-cancers-supplementary-app-i.xlsx
January 01, 2019 - ICEMAN - Primary studies
RefID Study name State a single candidate effect modifier Was the effect modifier measured before or at randomization/assignment? State a single outcome and time-point of interest State a single effect measure 1: Was the direction of the effect modification correctly hypothesized a priori? 1: …
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/principles-person-centered-oud-treatment
January 01, 2023 - An official website of the Department of Health & Human Services
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