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psnet.ahrq.gov/node/45414/psn-pdf
August 17, 2016 - The next wave of hospital innovation to make patients
safer.
August 17, 2016
Ghaferi AA; Myers C; Sutcliffe KM; Pronovost PJ.
https://psnet.ahrq.gov/issue/next-wave-hospital-innovation-make-patients-safer
Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and…
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psnet.ahrq.gov/node/50663/psn-pdf
November 13, 2019 - Investigation into Electronic Prescribing and Medicines
Administration Systems and Safe Discharge.
November 13, 2019
Farnborough, UK: Healthcare Safety Investigation Branch; October 2019.
https://psnet.ahrq.gov/issue/investigation-electronic-prescribing-and-medicines-administration-systems-
and-safe-discharge
Des…
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psnet.ahrq.gov/node/45226/psn-pdf
January 04, 2017 - AHRQ Research Summit on Improving Diagnosis in
Health Care.
January 4, 2017
Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016.
https://psnet.ahrq.gov/issue/ahrq-research-summit-improving-diagnosis-health-care
Research is increasingly focusing on diagnostic errors and strategies to reduc…
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psnet.ahrq.gov/node/46039/psn-pdf
April 05, 2017 - Retained lumbar catheter tip.
April 5, 2017
DeLancey JO, Barnard C, Bilimoria KY. Retained Lumbar Catheter Tip. JAMA. 2017;317(12):1269-1270.
doi:10.1001/jama.2017.1713.
https://psnet.ahrq.gov/issue/retained-lumbar-catheter-tip
Retained surgical items are considered a sentinel event. Discussing an incident involvi…
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psnet.ahrq.gov/node/865819/psn-pdf
May 08, 2024 - Focus on HARM (Harmonizing Accountability in
Reporting and Monitoring).
May 8, 2024
National Quality Forum.
https://psnet.ahrq.gov/issue/focus-harm-harmonizing-accountability-reporting-and-monitoring
Strong incident reporting systems are a foundational component for understanding preventable health care
error. Th…
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psnet.ahrq.gov/node/42330/psn-pdf
June 12, 2013 - Creating a culture of safety in the emergency department:
the value of teamwork training.
June 12, 2013
Jones F, Podila P, Powers C. Creating a culture of safety in the emergency department: the value of
teamwork training. J Nurs Adm. 2013;43(4):194-200. doi:10.1097/NNA.0b013e31828958cd.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/46708/psn-pdf
February 08, 2023 - FDA/ISMP Safe Medication Management Fellowship
Program.
February 8, 2023
Food and Drug Administration, Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/fdaismp-safe-medication-management-fellowship-program
This fellowship program provides clinicians with learning opportunities at the Institute…
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psnet.ahrq.gov/node/42765/psn-pdf
November 30, 2016 - Advancing Patient Safety Implementation Through Safe
Medication Use Research (R18).
November 30, 2016
Rockville, MD: Agency for Healthcare Research and Quality. PA-14-002.
https://psnet.ahrq.gov/issue/advancing-patient-safety-implementation-through-safe-medication-use-
research-r18
This funding program will suppo…
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psnet.ahrq.gov/node/39609/psn-pdf
June 27, 2010 - Identification and Prevention of Common Adverse Drug
Events in the Intensive Care Unit.
June 27, 2010
Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.
https://psnet.ahrq.gov/issue/identification-and-prevention-common-adverse-drug-events-intensive-care-unit
This supplem…
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psnet.ahrq.gov/node/48183/psn-pdf
August 07, 2019 - Get the Medications Right Institute.
August 7, 2019
8230 Old Courthouse Road, Suite 420, Tysons Corner, VA.
https://psnet.ahrq.gov/issue/get-medications-right-institute
A comprehensive systems-focused approach must be employed in the hospital and at home to ensure
reliable medication use. This institute supports m…
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digital.ahrq.gov/ahrq-funded-projects/success-stories/text-messaging-managing-chronic-disease
January 01, 2023 - Text Messaging for Managing Chronic Disease
Your browser does not support inline frames. Please go to http://youtu.be/bpP8xawfoi4 to view the video. Principal Investigator: Jennifer Uhrig (Contract No. HHSA290200600001I #7) [5 min., 10 sec.] This project showed that text messaging can effec…
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psnet.ahrq.gov/node/39020/psn-pdf
October 14, 2009 - A critical review of the systems approach within patient
safety research.
October 14, 2009
Waterson P. A critical review of the systems approach within patient safety research. Ergonomics.
2009;52(10):1185-1195. doi:10.1080/00140130903042782.
https://psnet.ahrq.gov/issue/critical-review-systems-approach-within-pat…
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psnet.ahrq.gov/node/41009/psn-pdf
December 21, 2011 - Improving ambulatory patient safety: learning from the
last decade, moving ahead in the next.
December 21, 2011
Wynia MK, Classen DC. Improving Ambulatory Patient Safety. JAMA. 2011;306(22):2504-2505.
doi:10.1001/jama.2011.1820.
https://psnet.ahrq.gov/issue/improving-ambulatory-patient-safety-learning-last-decade-…
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psnet.ahrq.gov/node/72863/psn-pdf
March 17, 2021 - 7 ways to prevent medical errors.
March 17, 2021
Caceres V. US News World Report. March 1, 2021.
https://psnet.ahrq.gov/issue/7-ways-prevent-medical-errors
Patients and families have an important role in reducing potential for error and harm. This article highlights
a set of tactics for patients to enhan…
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www.ahrq.gov/nursing-home/index.html
Nursing Home COVID-19 Action Network
About AHRQ's Nursing Home Network
The network provides free training and mentorship to nursing homes across the country.
5-Minute Learn…
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digital.ahrq.gov/ahrq-funded-projects/enhancing-patient-matching-support-operational-health-information-exchange/citation/incorporating
January 01, 2023 - Incorporating conditional dependence in latent class models for probabilistic record linkage: Does it matter?.
Citation
Huiping Xu. Xiaochun Li. Changyu Shen. Siu L. Hui. Shaun Grannis. "Incorporating conditional dependence in latent class models for probabilistic record linkage: Does it matter?." Ann…
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digital.ahrq.gov/ahrq-funded-projects/enhancing-patient-matching-support-operational-health-information-exchange/citation/data
January 01, 2023 - The data-adaptive Fellegi-Sunter model for probabilistic record linkage: Algorithm development and validation for incorporating missing data and field selection.
Citation
Li X, Xu H, Grannis S. The data-adaptive Fellegi-Sunter model for probabilistic record linkage: Algorithm development and validatio…
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psnet.ahrq.gov/node/39384/psn-pdf
March 24, 2010 - Keeping safety a priority in home care and hospice: one
agency's journey.
March 24, 2010
Mullin LV. Keeping safety a priority in home care and hospice: one agency's journey. Home Healthc Nurse.
2010;28(2):63-70. doi:10.1097/NHH.0b013e3181cb5939.
https://psnet.ahrq.gov/issue/keeping-safety-priority-home-care-and-ho…
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psnet.ahrq.gov/node/39781/psn-pdf
November 23, 2016 - Advancing Effective Communication, Cultural
Competence, and Patient- and Family-Centered Care: A
Roadmap for Hospitals.
November 23, 2016
Oakbrook Terrace, IL: The Joint Commission; 2010.
https://psnet.ahrq.gov/issue/advancing-effective-communication-cultural-competence-and-patient-and-
family-centered-care
This…
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psnet.ahrq.gov/node/43920/psn-pdf
July 10, 2018 - Master of Science in Medical and Healthcare Simulation.
July 10, 2018
Drexel University College of Medicine.
https://psnet.ahrq.gov/issue/master-science-medical-and-healthcare-simulation
Simulation training enables learning from mistakes without the potential for patient harm. This
multidisciplinary degree program…