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psnet.ahrq.gov/node/838917/psn-pdf
October 26, 2022 - The e-Autopsy/e-Biopsy: a systematic chart review to
increase safety and diagnostic accuracy.
October 26, 2022
Kanter MH, Ghobadi A, Lurvey LD, et al. The e-Autopsy/e-Biopsy: a systematic chart review to increase
safety and diagnostic accuracy. Diagnosis (Berl). 2022;9(4):430-436. doi:10.1515/dx-2022-0083.
https:/…
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psnet.ahrq.gov/node/865486/psn-pdf
April 03, 2024 - Clinical informatics team members' perspectives on
health information technology safety after experiential
learning and safety process development: qualitative
descriptive study.
April 3, 2024
Recsky C, Rush KL, MacPhee M, et al. Clinical informatics team members' perspectives on health
information technology saf…
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psnet.ahrq.gov/node/853240/psn-pdf
September 06, 2023 - Videos of simulated after action reviews: a training
resource to support social and inclusive learning from
patient safety events.
September 6, 2023
McCarthy SE, Hogan C, Jenkins L, et al. Videos of simulated after action reviews: a training resource to
support social and inclusive learning from patient safety eve…
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psnet.ahrq.gov/node/47422/psn-pdf
October 31, 2018 - The influence of stress responses on surgical
performance and outcomes: literature review and the
development of the surgical stress effects (SSE)
framework.
October 31, 2018
Chrouser KL, Xu J, Hallbeck S, et al. The influence of stress responses on surgical performance and
outcomes: Literature review and the dev…
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psnet.ahrq.gov/node/35908/psn-pdf
March 03, 2011 - Patient safety in surgery.
March 3, 2011
Makary MA, Sexton B, Freischlag JA, et al. Patient safety in surgery. Ann Surg. 2006;243(5):628-32;
discussion 632-5.
https://psnet.ahrq.gov/issue/patient-safety-surgery
This AHRQ-supported study used a surgery-specific safety questionnaire (modified from the Safety
Attitu…
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psnet.ahrq.gov/node/836929/psn-pdf
April 13, 2022 - The impact of "missed nursing care" or "care not done"
on adults in health care: a rapid review for the Consensus
Development Project.
April 13, 2022
Willis E, Brady C. The impact of “missed nursing care” or “care not done” on adults in health care: A rapid
review for the Consensus Development Project. Nurs Open. …
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psnet.ahrq.gov/node/46631/psn-pdf
March 20, 2018 - Simulation-based education to ensure provider
competency within the healthcare system.
March 20, 2018
Griswold S, Fralliccardi A, Boulet J, et al. Simulation-based Education to Ensure Provider Competency
Within the Health Care System. Acad Emerg Med. 2018;25(2):168-176. doi:10.1111/acem.13322.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/45962/psn-pdf
April 24, 2018 - Bridging leadership roles in quality and patient safety:
experience of 6 US academic medical centers.
April 24, 2018
Myers JS, Tess A, McKinney K, et al. Bridging Leadership Roles in Quality and Patient Safety: Experience
of 6 US Academic Medical Centers. J Grad Med Educ. 2017;9(1):9-13. doi:10.4300/JGME-D-16-00065…
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psnet.ahrq.gov/node/853619/psn-pdf
September 20, 2023 - Defining speaking up in the healthcare system: a
systematic review.
September 20, 2023
Kane J, Munn L, Kane SF, et al. Defining speaking up in the healthcare system: a systematic review. J Gen
Intern Med. 2023;38(15):3406-3413. doi:10.1007/s11606-023-08322-0.
https://psnet.ahrq.gov/issue/defining-speaking-healthca…
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psnet.ahrq.gov/node/45490/psn-pdf
September 01, 2018 - Collaboration with regulators to support quality and
accountability following medical errors: the
communication and resolution program certification pilot.
September 1, 2018
Gallagher TH, Farrell ML, Karson H, et al. Collaboration with Regulators to Support Quality and
Accountability Following Medical Errors: The …
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psnet.ahrq.gov/node/46538/psn-pdf
February 21, 2018 - Adverse events in patients in home healthcare: a
retrospective record review using trigger tool
methodology.
February 21, 2018
Schildmeijer KGI, Unbeck M, Ekstedt M, et al. Adverse events in patients in home healthcare: a
retrospective record review using trigger tool methodology. BMJ Open. 2018;8(1):e019267.
doi…
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psnet.ahrq.gov/node/73085/psn-pdf
January 01, 2022 - Multiple meanings of resilience: health professionals'
experiences of a dual element training intervention
designed to help them prepare for coping with error.
March 31, 2021
Janes G, Harrison R, Johnson J, et al. Multiple meanings of resilience: health professionals' experiences of
a dual element training interve…
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psnet.ahrq.gov/node/72657/psn-pdf
January 20, 2021 - Establishing a multi-institutional quality and patient
safety consortium: collaboration across affiliates in a
community-based medical school.
January 20, 2021
Hillman E, Paul J, Neustadt M, et al. Establishing a multi-institutional quality and patient safety consortium:
collaboration across affiliates in a commun…
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www.ahrq.gov/pqmp/implementation-qi/toolkit/h2h/introduction.html
July 01, 2021 - Quality of Pediatric Hospital-to-Home Transitions Toolkit
Introduction
Previous Page Next Page
Table of Contents
Quality of Pediatric Hospital-to-Home Transitions Toolkit
Introduction
Overview
About the Measure
Key Driver Diagram
Quality Improvement Strategies
Improvement Data
Other Re…
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psnet.ahrq.gov/node/47618/psn-pdf
January 30, 2019 - Making care better in the pediatric intensive care unit.
January 30, 2019
Wolfe HA, Mack EH. Making care better in the pediatric intensive care unit. Transl Pediatr. 2018;7(4):267-
274. doi:10.21037/tp.2018.09.10.
https://psnet.ahrq.gov/issue/making-care-better-pediatric-intensive-care-unit
Pediatric critical care…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit2.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 2. Factors Considered in Organization Selection
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Cas…
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psnet.ahrq.gov/node/863222/psn-pdf
February 28, 2024 - Systematic review of morbidity and mortality meeting
standardization: does it lead to improved professional
development, system improvements, clinician
engagement, and enhanced patient safety culture?
February 28, 2024
Steel EJ, Janda M, Jamali S, et al. Systematic review of morbidity and mortality meeting standar…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/033-ss-action-chart-decolonization.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Action Chart for Implementing a
Preoperative Decolonization Program
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
CUSP = Comprehensive Unit-based Safety Program; MRSA = methicillin-resistant Staphylococcus au…
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digital.ahrq.gov/care-setting/ambulance
January 01, 2023 - Ambulance
Digital EMS Point-of-Care Innovation to Improve Rural STEMI Outcomes
Description
This research will develop, implement, refine, and evaluate an app to support clinical decisions for ST-Elevation Myocardial Infarction care in rural areas by emergency medical services …
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www.ahrq.gov/hai/cusp/videos/index.html
September 01, 2019 - CUSP Videos
The following videos give examples of CUSP practices.
Introduction
About CUSP—A Doctor's Perspective
About CUSP: A Nurse's Perspective
About CUSP: Overview
Assemble the Team
The 4 E's
Building Your CUSP Team
Psychological Safety
Physician Engagement
Engage the Senior Executive
…