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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-patient-family-engagement.pdf
July 01, 2023 - EHC Protocol: Addressing Social Isolation To Improve Health of Older Adults: A Rapid Evidence Review
Evidence-based Practice Center Rapid Response Protocol
Project Title: Making Healthcare Safer IV: Patient and Family
Engagement
Review Questions
1. What is the frequency and severity of harms addre…
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart
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June 12, 2020
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www.ahrq.gov/sites/default/files/2024-12/moyer-report.pdf
January 01, 2024 - Final Progress Report: Crossing an Invisible Quality Chasm: From NICU to Ambulatory Care
AHRQ Grant Final Progress Report
Title:
Crossing An Invisible Quality Chasm: From NICU to Ambulatory Care
Principal Investigator:
Virginia A. Moyer, MD, MPH
Team Members:
Papile, Lucille A., MD, Co-Investigator
Guillory, Char…
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www.ahrq.gov/sites/default/files/2024-04/baernholdt-report.pdf
January 01, 2024 - Final Progress Report: Care Interventions and Quality of Care in Rural and Urban Nursing Units
Title of Project: Care Interventions and Quality of Care in Rural and Urban Nursing
Units
Principal Investigator and Team Members:
PI: Marianne Baernholdt, PhD, MPH, RN, Virginia Commonwealth University, School of
N…
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hcup-us.ahrq.gov/db/nation/nass/nasschecklist.jsp
November 01, 2024 - Checklist for Working with the NASS
An official website of the Department of Health & Human Services
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Arroyo.pdf
June 11, 2003 - A Nonpunitive, Computerized System for Improved Reporting of Medical Occurrences
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A Nonpunitive, Computerized System for
Improved Reporting of Medical Occurrences
Dale A. Arroyo
Abstract
To improve the patient safety program at the Naval Hospital at Oak Harbor, the
facility instituted a new computerized s…
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psnet.ahrq.gov/issue/devil-detail-how-closed-loop-documentation-system-iv-infusion-administration-contributes-and
February 12, 2020 - Study
The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety.
Citation Text:
Furniss D, Dean Franklin B, Blandford A. The devil is in the detail: how a closed-loop documentation system for IV infusi…
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psnet.ahrq.gov/issue/designing-distractions-human-factors-approach-decreasing-interruptions-centralised-medication
July 27, 2018 - Study
Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.
Citation Text:
Colligan L, Guerlain S, Steck SE, et al. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication…
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psnet.ahrq.gov/issue/evaluation-problem-specific-sbar-tool-improve-after-hours-nurse-physician-phone-communication
December 30, 2014 - Study
Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial.
Citation Text:
Joffe E, Turley JP, Hwang KO, et al. Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a ra…
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psnet.ahrq.gov/issue/effect-electronic-transmission-prescriptions-dispensing-errors-and-prescription-enhancements
December 16, 2020 - Study
The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.
Citation Text:
Franklin BD, Reynolds M, Sadler S, et al. The effect of the electronic transmission…
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psnet.ahrq.gov/issue/diagnostic-discrepancies-between-antemortem-clinical-diagnosis-and-autopsy-findings-pediatric
July 28, 2021 - Study
Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.
Citation Text:
Raghuram N, Alodan K, Bartels U, et al. Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.…
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digital.ahrq.gov/ahrq-funded-projects/best-practices-integrating-clinical-decision-support-clinical-workflow
January 01, 2023 - Best Practices For Integrating Clinical Decision Support Into Clinical Workflow
Project Final Report ( PDF , 513.15 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily re…
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psnet.ahrq.gov/issue/fall-prevention-smart-socks-system-reduces-hospital-fall-rates
September 09, 2020 - Study
Fall prevention with the Smart Socks System reduces hospital fall rates.
Citation Text:
Moore T, Kline D, Palettas M, et al. Fall prevention with the Smart Socks System reduces hospital fall rates. J Nurs Care Qual. 2023;38(1):55-60. doi:10.1097/ncq.0000000000000653.
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digital.ahrq.gov/principal-investigator/casale-cecilia
January 01, 2023 - Casale, Cecilia
Health information technology and quality of health care: strategies for reducing disparities in underresourced settings.
Citation
Millery M, Kukafka R. Health information technology and quality of health care: strategies for reducing disparities in underresour…
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psnet.ahrq.gov/issue/reducing-risk-delayed-colorectal-cancer-diagnoses-through-ambulatory-safety-net-collaborative
February 28, 2011 - Study
Reducing the risk of delayed colorectal cancer diagnoses through an ambulatory safety net collaborative.
Citation Text:
Moyal-Smith R, Elam M, Boulanger J, et al. Reducing the risk of delayed colorectal cancer diagnoses through an ambulatory safety net collaborative. Jt Comm J Qual…
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psnet.ahrq.gov/issue/identifying-barriers-and-opportunities-telehealth-implementation-amidst-covid-19-pandemic
July 07, 2021 - Commentary
Identifying barriers to and opportunities for telehealth implementation amidst the COVID-19 pandemic by using a human factors approach: a leap into the future of health care delivery?
Citation Text:
Zhang T, Mosier J, Subbian V. Identifying barriers to and opportunities for te…
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psnet.ahrq.gov/issue/safety-pediatric-hospice-and-palliative-care-qualitative-study
September 02, 2020 - Study
Safety in pediatric hospice and palliative care: a qualitative study.
Citation Text:
Pestian T, Thienprayoon R, Grossoehme D, et al. Safety in pediatric hospice and palliative care: a qualitative study. Pediatr Qual Saf. 2020;5(4):e328. doi:10.1097/pq9.0000000000000328.
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psnet.ahrq.gov/issue/unintended-consequences-online-consultations-qualitative-study-uk-primary-care
November 16, 2022 - Study
Unintended consequences of online consultations: a qualitative study in UK primary care.
Citation Text:
Turner A, Morris R, Rakhra D, et al. Unintended consequences of online consultations: a qualitative study in UK primary care. Br J Gen Pract. 2021;72(715):e128-e137. doi:10.3399/…
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psnet.ahrq.gov/issue/observational-study-how-patients-are-identified-medication-administrations-medical-and
June 24, 2020 - Study
An observational study of how patients are identified before medication administrations in medical and surgical wards.
Citation Text:
Härkänen M, Kervinen M, Ahonen J, et al. An observational study of how patients are identified before medication administrations in medical and surg…
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psnet.ahrq.gov/issue/patient-participation-patient-safety-still-missing-patient-safety-experts-views
February 13, 2019 - Study
Patient participation in patient safety still missing: patient safety experts' views.
Citation Text:
Sahlström M, Partanen P, Rathert C, et al. Patient participation in patient safety still missing: Patient safety experts' views. Int J Nurs Pract. 2016;22(5):461-469. doi:10.1111/ij…