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www.ahrq.gov/news/newsroom/case-studies/202501.html
January 01, 2025 - Henry Ford Hospital Unit Lowers C. diff Infections by 90 Percent Using AHRQ Safety Program
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January 2025
Using AHRQ’s Comprehensive Unit-based Safety Program (CUSP ), Henry Ford Hospital in Detroit reduced the incidence of Clostridioides difficile (C. diff) infections in its…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/128-what-are-4es-one-pager.docx
April 01, 2025 - The 4 Es framework identifies four important elements when implementing patient safety interventions: Engage, Educate, Execute, and Evaluate. This framework integrates well with the Comprehensive Unit-based Safety Program (CUSP) and addresses both the technical objectives of improving practices and the adaptive objecti…
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psnet.ahrq.gov/issue/clinical-scenarios-enhancing-skill-set-nurse-vigilant-guardian
July 19, 2023 - Study
Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian.
Citation Text:
Jacobson T, Belcher E, Sarr B, et al. Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian. J Contin Educ Nurs. 2010;41(8):347-53; quiz 354-5. doi:10.3928/0…
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digital.ahrq.gov/program-overview/research-stories/asthmaxcel-pro-mobile-application-support-asthma-chronic-disease-management
January 01, 2023 - ASTHMAXcel PRO Mobile Application to Support Asthma Chronic Disease Management
Theme:
Engaging and Empowering Patients and Caregivers
Subtheme:
Using Digital Healthcare Tools in Chronic Disease Self-Management
A mobile application designed to facilitate asthma self-management and shared de…
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psnet.ahrq.gov/issue/act-performance-exploring-residents-decision-making-processes-seek-help
October 13, 2021 - Study
An act of performance: exploring residents' decision-making processes to seek help.
Citation Text:
Jansen I, Stalmeijer RE, Silkens MEWM, et al. An act of performance: exploring residents’ decision‐making processes to seek help. Med Educ. 2021;55(6):758-767. doi:10.1111/medu.14465.…
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psnet.ahrq.gov/issue/using-computerized-virtual-cases-explore-diagnostic-error-practicing-physicians
August 20, 2018 - Study
Using computerized virtual cases to explore diagnostic error in practicing physicians.
Citation Text:
Trowbridge RL, Reilly JB, Clauser JC, et al. Using computerized virtual cases to explore diagnostic error in practicing physicians. Diagnosis (Berl). 2018;5(4):229-233. doi:10.1515…
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psnet.ahrq.gov/issue/applying-lessons-social-psychology-transform-culture-error-disclosure
March 20, 2024 - Commentary
Applying lessons from social psychology to transform the culture of error disclosure.
Citation Text:
Han J, LaMarra D, Vapiwala N. Applying lessons from social psychology to transform the culture of error disclosure. Med Educ. 2017;51(10):996-1001. doi:10.1111/medu.13345.
Co…
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psnet.ahrq.gov/issue/qualitative-survey-factors-shaping-role-safety-professional
August 12, 2020 - Study
A qualitative survey of factors shaping the role of a safety professional.
Citation Text:
Van Wassenhove W, Foussard C, Dekker SWA, et al. A qualitative survey of factors shaping the role of a safety professional. Safety Sci. 2022;154:105835. doi:10.1016/j.ssci.2022.105835.
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psnet.ahrq.gov/issue/multidisciplinary-obstetric-simulated-emergency-scenarios-moses-promoting-patient-safety
March 25, 2009 - Study
Multidisciplinary obstetric simulated emergency scenarios (MOSES): promoting patient safety in obstetrics with teamwork-focused interprofessional simulations.
Citation Text:
Freeth D, Ayida G, Berridge EJ, et al. Multidisciplinary obstetric simulated emergency scenarios (MOSES): p…
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psnet.ahrq.gov/issue/pursuing-excellence-collaborative-engaging-first-year-residents-and-fellows-patient-safety
September 15, 2011 - Commentary
The Pursuing Excellence Collaborative: engaging first-year residents and fellows in patient safety event investigations.
Citation Text:
Paull DE, Newton RC, Tess AV, et al. The Pursuing Excellence Collaborative: engaging first-year residents and fellows in patient safety event…
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psnet.ahrq.gov/issue/understanding-psychological-safety-health-care-and-education-organizations-comparative
July 30, 2014 - Commentary
Understanding psychological safety in health care and education organizations: a comparative perspective.
Citation Text:
Edmondson AC, Higgins M, Singer SJ, et al. Understanding Psychological Safety in Health Care and Education Organizations: A Comparative Perspective. Res Hum…
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psnet.ahrq.gov/issue/impact-pharmacist-involvement-transitional-care-high-risk-patients-through-medication
August 25, 2011 - Review
Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study).
Citation Text:
Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transition…
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psnet.ahrq.gov/issue/so-why-didnt-you-think-baby-was-ill-decision-making-acute-paediatrics
April 10, 2019 - Review
'So why didn't you think this baby was ill?' Decision-making in acute paediatrics.
Citation Text:
Roland D, Snelson E. 'So why didn't you think this baby was ill?' Decision-making in acute paediatrics. Arch Dis Child Educ Pract Ed. 2019;104(1):43-48. doi:10.1136/archdischild-2017-…
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psnet.ahrq.gov/issue/sorry-i-meant-patients-left-side-impact-distraction-left-right-discrimination
July 10, 2024 - Study
'Sorry, I meant the patient's left side': impact of distraction on left-right discrimination.
Citation Text:
McKinley J, Dempster M, Gormley GJ. 'Sorry, I meant the patient's left side': impact of distraction on left-right discrimination. Med Educ. 2015;49(4):427-35. doi:10.1111/me…
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psnet.ahrq.gov/issue/acgme-summary-report-pursuing-excellence-pathway-leaders-patient-safety-collaborative
October 18, 2017 - Book/Report
ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative.
Citation Text:
ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative. Passiment M, Wagner R, Weiss KB for the Pursuing Excellence in Clinical Learn…
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psnet.ahrq.gov/issue/internal-medicine-trainees-views-training-adequacy-and-duty-hours-restrictions-2009
August 20, 2018 - Study
Internal medicine trainees' views of training adequacy and duty hours restrictions in 2009.
Citation Text:
Shea JA, Weissman A, McKinney S, et al. Internal medicine trainees' views of training adequacy and duty hours restrictions in 2009. Acad Med. 2012;87(7):889-94. doi:10.1097/AC…
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psnet.ahrq.gov/issue/prospective-pilot-intervention-study-prevent-medication-errors-drugs-administered-children
December 04, 2015 - Study
Prospective pilot intervention study to prevent medication errors in drugs administered to children by mouth or gastric tube: a programme for nurses, physicians and parents.
Citation Text:
Bertsche T, Bertsche A, Krieg E-M, et al. Prospective pilot intervention study to prevent m…
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psnet.ahrq.gov/issue/student-mistakes-and-teacher-reactions-bedside-teaching
January 18, 2012 - Study
Student mistakes and teacher reactions in bedside teaching.
Citation Text:
Rubisch HPK, Blaschke A-L, Berberat PO, et al. Student mistakes and teacher reactions in bedside teaching. Adv Health Sci Educ Theory Pract. 2023;28(5):1523-1556. doi:10.1007/s10459-023-10233-y.
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psnet.ahrq.gov/issue/development-and-evaluation-3-day-patient-safety-curriculum-advance-knowledge-self-efficacy
July 01, 2016 - Study
Development and evaluation of a 3-day patient safety curriculum to advance knowledge, self-efficacy and system thinking among medical students.
Citation Text:
Aboumatar HJ, Thompson DA, Wu AW, et al. Development and evaluation of a 3-day patient safety curriculum to advance knowl…
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psnet.ahrq.gov/issue/understanding-healthcare-workplace-learning-culture-through-safety-and-dignity-narratives-uk
August 06, 2014 - Study
Understanding the healthcare workplace learning culture through safety and dignity narratives: a UK qualitative study of multiple stakeholders' perspectives.
Citation Text:
Sholl S, Scheffler G, Monrouxe L, et al. Understanding the healthcare workplace learning culture through safe…