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psnet.ahrq.gov/node/36632/psn-pdf
July 28, 2010 - Operating room briefings and wrong-site surgery.
July 28, 2010
Makary MA, Mukherjee A, Sexton B, et al. Operating room briefings and wrong-site surgery. J Am Coll
Surg. 2007;204(2):236-43.
https://psnet.ahrq.gov/issue/operating-room-briefings-and-wrong-site-surgery
Although wrong-site surgeries are rare, they have…
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psnet.ahrq.gov/node/846443/psn-pdf
March 22, 2023 - Closed-loop communication in interprofessional
emergency teams: a cross-sectional observation study on
the use of closed-loop communication among anesthesia
personnel.
March 22, 2023
Gjøvikli K, Valeberg BT. Closed-loop communication in interprofessional emergency teams: a cross-
sectional observation study on th…
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psnet.ahrq.gov/node/38414/psn-pdf
March 31, 2009 - Patient safety incidents associated with airway devices in
critical care: a review of reports to the UK National Patient
Safety Agency.
March 31, 2009
Thomas AN, McGrath BA. Patient safety incidents associated with airway devices in critical care: a review
of reports to the UK National Patient Safety Agency. Anaes…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apd.html
August 01, 2022 - Gap Analysis Facilitator's Guide: Appendix D
Anonymous Reporting Tool
The Gap Analysis process relies heavily on key informant interviews and perspectives, which often take place in a focus group setting. Many times individuals have additional, more sensitive information to share, or information/observations …
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www.ahrq.gov/patient-safety/resources/designer-guide/index.html
December 01, 2017 - Bringing Human Factors into Home Health Care
Institute of Medicine Report and Designer's Guide
Many health care technologies that involve information technology (IT) are moving into the home, for use by caregivers who look after the growing number of older adults with chronic illnesses. With funding from the …
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www.ahrq.gov/sdoh/data-analytics/sdoh-beta-database.html
July 01, 2022 - Social Determinants of Health Database (Beta Version) - Archived
This archived SDOH Database (beta version) is available for reference. The most recent version of the SDOH Database replaces the beta version and is available on the main page . To ensure consistency in variable names and construction, analyses s…
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www.ahrq.gov/topics/transitions-care.html
Transitions of Care
AHRQ's tools and research to ensure safe and seamless transitions of patients from one care setting to another, reducing preventable adverse events, drug-related errors, and other problems.
Tools TeamSTEPPS Module on Communication
Toolkit to Engage High-Risk P…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-creative-strategies-transcript.pdf
April 01, 2019 - And part of delivering high-value care is ensuring a positive patient experience, not just higher clinical … One of the big issues
in ensuring a positive patient experience is care coordination. … So ensuring that we have the advocacy
and the support of others in the organization is really important
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/applycusp.pptx
August 18, 2011 - (“Apply CUSP” cover slide with CUSP Toolkit logo)
1
Learning Objectives
Review key steps of the CUSP Toolkit
Learn how Just Culture principles can augment CUSP
2
Introduce Just Culture principles
2
Introduction to Just Culture Principles
3
3
Understand Just Culture
4
4
Just Culture1
A system t…
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www.ahrq.gov/policymakers/chipra/demoeval/demostates/il.html
March 01, 2019 - State at a Glance: Illinois
Learn more about the CHIPRA quality demonstration projects being implemented in Illinois.
Illinois is featured in the following reports from the National Evaluation:
Evaluation Highlight No. 2 : How are States and evaluators measuring medical homeness in the CHIPRA Quality Demo…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-mupirocin.docx
March 01, 2022 - FAQs (Staff): Nasal Mupirocin for MRSA-Positive Patients With Devices
Decolonization of
Non-ICU Patients With Devices
Section 14-2 – Addressing Questions Asked by Staff:
Nasal Mupirocin for MRSA Carriers With Devices
What is mupirocin and how safe is it?
Mupirocin is a topical antibiotic ointment to prevent infe…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/sustain-slides.pptx
November 01, 2019 - Improving Antibiotic Use is a Patient Safety Issue
Sustaining Stewardship Activities
Acute Care
AHRQ Safety Program for Improving Antibiotic Use
AHRQ Pub. No. 17(20)-0028-EF
November 2019
AHRQ Safety Program for Improving Antibiotic Use – Acute Care
Sustaining Stewardship
1
Objectives
Review the goals of an anti…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/assembling-cusp-team.pdf
April 01, 2022 - Making It Work Tip Sheet: Assembling the CUSP Team
AHRQ Safety Program for Intensive Care Units:
Preventing CLABSI and CAUTI
Making It Work Tip Sheet
Assembling the CUSP Team
This “Making It Work” tip sheet provides additional information to help intensive care unit (ICU) team
leaders implement effect…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-150-metabolic-monitoring-testing-summary.pdf
December 31, 2015 - CHIPRA 150 Section 6, Antipsychotics Testing Summary
Measure Submission Summary
Measure Name
Metabolic Monitoring for Children and Adolescents on Antipsychotics
Measure Number:
0150
NQF ID:
NA
Collection:
NA
Set…
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cdsic.ahrq.gov/cdsic/patient-preferences-topic-highlight
June 25, 2025 - :
Skip to main content
HHS.gov
Menu
Main navigation
CDS Home
CDS Innovation Collaborative
An official website of the Department of Health & Human Services
…
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cdsic.ahrq.gov/cdsic/srf-environmental-scan-report
January 01, 2023 - :
Skip to main content
HHS.gov
Menu
Main navigation
CDS Home
CDS Innovation Collaborative
An official website of the Department of Health & Human Services
…
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www.ahrq.gov/sites/default/files/wysiwyg/topics/diagnostic-safety-workgroupmeeting-notes-july2022.pdf.pdf
November 03, 2022 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare
Federal Interagency Workgroup:
Improving Diagnostic Safety and Quality in Healthcare
July Meeting Summary
Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on
Appropriations requested that “A…
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www.ahrq.gov/evidencenow/tools/keydrivers/implement-qi.html
November 01, 2018 - Key Driver 2: Implement a Data-driven Quality Improvement Process to Integrate Evidence into Practice Procedures
Print this page to PDF
Evidence is always evolving, so practices have to change if they are to stay current. Quality improvement (QI) is a systematic, data-driven process for managing that change. …
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/2024-virtual-research-meeting-summary-prems-proms.pdf
January 01, 2024 - measures, provide an important counterbalance to the cost accountability of
value-based payment models, ensuring … Selecting the right tools involves balancing meaningful and pragmatic data and ensuring
accessibility
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psnet.ahrq.gov/node/49773/psn-pdf
July 01, 2016 - Near Miss With Neonate
October 1, 2016
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/near-miss-neonate
The Case
A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm
dates. Early the next morning, intravenous oxy…