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psnet.ahrq.gov/issue/rates-serious-surgical-errors-california-and-plans-prevent-recurrence
March 09, 2022 - Study
Rates of serious surgical errors in California and plans to prevent recurrence.
Citation Text:
Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent recurrence. JAMA Netw Open. 2021;4(5):e217058. doi:10.1001/jamanetworkopen.2021.7058. …
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psnet.ahrq.gov/issue/outcomes-associated-nationwide-introduction-rapid-response-systems-netherlands
January 18, 2013 - Study
Outcomes associated with the nationwide introduction of rapid response systems in the Netherlands.
Citation Text:
Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf MGW, et al. Outcomes Associated With the Nationwide Introduction of Rapid Response Systems in The Netherlands. Crit Care …
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psnet.ahrq.gov/issue/consensus-statement-effective-communication-urgent-diagnoses-and-significant-unexpected
November 16, 2022 - Organizational Policy/Guidelines
Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology.
Cit…
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psnet.ahrq.gov/issue/effects-multimodal-transitional-care-intervention-patients-high-risk-readmission-target-read
August 18, 2021 - Study
Effects of a multimodal transitional care intervention in patients at high risk of readmission: the TARGET-READ randomized clinical trial.
Citation Text:
Donzé JD, John G, Genné D, et al. Effects of a multimodal transitional care intervention in patients at high risk of readmission…
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psnet.ahrq.gov/issue/adverse-events-intensive-care-and-continuing-care-units-during-bed-bath-procedures
March 05, 2025 - Study
Adverse events in intensive care and continuing care units during bed-bath procedures: the prospective observational NURSIng during critical carE (NURSIE) study.
Citation Text:
Decormeille G, Maurer-Maouchi V, Mercier G, et al. Adverse events in intensive care and continuing care u…
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psnet.ahrq.gov/issue/mixed-methods-evaluation-real-time-safety-reporting-hospitalized-patients-and-their-care
August 03, 2022 - Study
Mixed-methods evaluation of real-time safety reporting by hospitalized patients and their care partners: the MySafeCare application.
Citation Text:
Collins SA, Couture B, Smith A, et al. Mixed-Methods Evaluation of Real-Time Safety Reporting by Hospitalized Patients and Their Care …
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psnet.ahrq.gov/issue/how-does-audit-and-feedback-influence-intentions-health-professionals-improve-practice
February 14, 2024 - Study
How does audit and feedback influence intentions of health professionals to improve practice? A laboratory experiment and field study in cardiac rehabilitation.
Citation Text:
Gude WT, van Engen-Verheul MM, van der Veer SN, et al. How does audit and feedback influence intentions of…
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psnet.ahrq.gov/issue/protocolization-analgesia-and-sedation-through-smart-technology-intensive-care-improving
March 09, 2022 - Study
Protocolization of analgesia and sedation through smart technology in intensive care: improving patient safety.
Citation Text:
Ojeda IM, Sánchez-Cuervo M, Candela-Toha Á, et al. Protocolization of Analgesia and Sedation Through Smart Technology in Intensive Care: Improving Patient …
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www.ahrq.gov/news/newsroom/case-studies/cdom0803.html
October 01, 2014 - University of Iowa Uses AHRQ Data to Study Ways to Lower Incidence, Costs of Sports-Related Injuries
Search All Impact Case Studies
April 2008
Researchers at the University of Iowa College of Public Health used AHRQ's Nationwide Inpatient Sample (NIS), a database from the Healthcare Cost and Utilization Pro…
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psnet.ahrq.gov/issue/medication-errors-during-patient-transitions-nursing-homes-characteristics-and-association
August 07, 2013 - Study
Medication errors during patient transitions into nursing homes: characteristics and association with patient harm.
Citation Text:
Desai R, Williams CE, Greene SB, et al. Medication errors during patient transitions into nursing homes: characteristics and association with patient…
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psnet.ahrq.gov/issue/assessing-state-safe-medication-practices-using-ismp-medication-safety-self-assessment
March 02, 2016 - Study
Assessing the state of safe medication practices using the ISMP Medication Safety Self Assessment for Hospitals: 2000 and 2011.
Citation Text:
Vaida AJ, Lamis RL, Smetzer JL, et al. Assessing the State of Safe Medication Practices Using the ISMP Medication Safety Self Assessment ® …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4_pdi_bestpracticescover.pdf
June 02, 2025 - Introduction to the Pediatric Best Practices Tool
Pediatric Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
i Tool D.4
Introduction to the Pediatric Best Practices Tool
What is the purpose of this tool? The purpose of this tool is to provide:
• Detailed description of…
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psnet.ahrq.gov/issue/relationship-between-operating-room-teamwork-contextual-factors-and-safety-checklist
September 24, 2017 - Study
Relationship between operating room teamwork, contextual factors, and safety checklist performance.
Citation Text:
Singer SJ, Molina G, Li Z, et al. Relationship Between Operating Room Teamwork, Contextual Factors, and Safety Checklist Performance. J Am Coll Surg. 2016;223(4):568-5…
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psnet.ahrq.gov/issue/national-study-distribution-causes-and-consequences-voluntarily-reported-medication-errors
January 05, 2012 - Study
National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings.
Citation Text:
Latif A, Rawat N, Pustavoitau A, et al. National study on the distribution, causes, and consequences of voluntarily reported…
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www.ahrq.gov/news/newsroom/press-releases/sepsis-report-to-congress.html
September 01, 2024 - AHRQ Issues Report to Congress on Burden of Sepsis in U.S. Hospital Care
Report finds the emergence of COVID-19 significantly changed the epidemiology of sepsis
Press Release Date: September 16, 2024
The number of sepsis-related inpatient stays at non-federal acute care hospitals in the United States increased …
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www.ahrq.gov/news/blog/ahrqviews/portrait-of-sepsis.html
September 01, 2024 - AHRQ Views: Blog posts from AHRQ leaders
AHRQ’s Portrait of Sepsis Reveals Its Alarming Human Toll
SEP
27
2024
By
Robert Otto Valdez, Ph.D., M.H.S.A., and
Pamela Owens, Ph.D.
The human suffering caused by sepsis is shocking. New AHRQ analyses show that in 2021, more than 2 m…
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www.ahrq.gov/evidencenow/projects/heart-health/index.html
March 01, 2024 - Advancing Heart Health
An AHRQ Initiative
The Problem
The Nation's primary care practices have been challenged in recent decades by fragmentation of the healthcare system, a lack of resources to meet patient needs, and limited access to an infrastructure to support quality improvement (QI). As a result, m…
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psnet.ahrq.gov/issue/evidence-based-tool-pe-ps-healthcare-managers-assess-patient-engagement-patient-safety
June 08, 2010 - Study
An evidence-based tool (PE for PS) for healthcare managers to assess patient engagement for patient safety in healthcare organizations.
Citation Text:
Aho-Glele U, Pomey M-P, Gomes de Sousa MR, et al. An evidence-based tool (PE for PS) for healthcare managers to assess patient enga…
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psnet.ahrq.gov/issue/enhancing-patient-safety-and-quality-care-improving-usability-electronic-health-record
March 04, 2011 - Commentary
Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA.
Citation Text:
Middleton B, Bloomrosen M, Dente MA, et al. Enhancing patient safety and quality of care by improving the usability of electro…
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www.ahrq.gov/funding/grantee-profiles/grtprofile-schoenthaler.html
March 01, 2024 - Grantee Profile
Tailoring Digital Technologies To Improve Outcomes Among Minorities With Chronic Conditions
Antoinette Schoenthaler, Ed.D.
Associate Director of the Center for Healthful Behavior Change
New York University Langone Health
Antoinette Schoenthaler, Ed.D.
“Funding from AHRQ has b…