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www.ahrq.gov/sites/default/files/publications/files/implementation-guide_0.pdf
September 01, 2015 - Highlights the importance of patient and family
participation during the patient’s hospital stay, ensuring
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www.ahrq.gov/sites/default/files/2024-01/friese-report.pdf
January 01, 2024 - In other practices, it is the infusion nurses who are responsible for preparing orders and
ensuring
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/distributed-network-blueprint_research.pdf
June 01, 2010 - Ensuring that data holders can retain local control
over all uses and users of their data is a key issue … Protection of Proprietary Information
Data holders maintain the responsibility of protecting their data and ensuring
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psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - meaning that no care plan ought to be implemented without taking account of the patient’s preferences and ensuring … Approach to Improving Patient Safety
A Proposed Strategy for Ensuring Implementation of an Established
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/value-added-analysis
January 01, 2023 - Value-Added Analysis
Description
Value-added analysis is a method for identifying problems within a process. The analysis allows a team to examine individual process steps so it can separate the steps that add value for the user from the steps that do not.
Uses
When searching for sources of …
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/100-alabama-heart-health-improvement-collaborative-survey.docx
June 02, 2025 - You are invited to take part in a member survey for the Alabama Cardiovascular Cooperative/Heart Health Improvement Project. The survey includes 19 items related to your experience as a Cooperative Member along with questions related to our work in the future.
Strongly Disagree
Disagree
Neither Agree nor Disagree…
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psnet.ahrq.gov/node/46361/psn-pdf
May 23, 2018 - Inadequate hand-off communication.
May 23, 2018
Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6.
https://psnet.ahrq.gov/issue/inadequate-hand-communication
The Joint Commission publishes sentinel event alerts to draw attention to pressing or emerging safety
issues and provide guidelines fo…
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psnet.ahrq.gov/node/36836/psn-pdf
January 29, 2015 - Learning from Bristol: The Report of the Public Inquiry
into Children's Heart Surgery at the Bristol Royal
Infirmary 1984--1995.
January 29, 2015
Bristol Royal Infirmary Inquiry; The Stationery Office. London, England: Crown Copyright; 2002.
https://psnet.ahrq.gov/issue/learning-bristol-report-public-inquiry-child…
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psnet.ahrq.gov/node/60315/psn-pdf
May 13, 2020 - Safety at the time of the COVID-19 pandemic: how to keep
our oncology patients and healthcare workers safe.
May 13, 2020
Cinar P, Kubal T, Freifeld A, et al. Safety at the time of the COVID-19 pandemic: how to keep our oncology
patients and healthcare workers safe. J Natl Compr Canc Netw. 2020;18(5):504-509.
doi:1…
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psnet.ahrq.gov/node/856584/psn-pdf
January 01, 2024 - Patient safety incidents in endoscopy: a human factors
analysis of non-procedural significant harm incidents
from the National Reporting and Learning System (NRLS).
November 29, 2023
Ravindran S, Matharoo M, Rutter MD, et al. Patient safety incidents in endoscopy: a human factors
analysis of nonprocedural signific…
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psnet.ahrq.gov/node/37808/psn-pdf
February 22, 2011 - How do hospitalized patients feel about resident work
hours, fatigue, and discontinuity of care?
February 22, 2011
Fletcher KE, Wiest FC, Halasyamani L, et al. How do hospitalized patients feel about resident work hours,
fatigue, and discontinuity of care? J Gen Intern Med. 2008;23(5):623-8. doi:10.1007/s11606-007-…
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www.ahrq.gov/talkingquality/resources/checklist.html
February 01, 2019 - Your Project Checklist
The checklists below are designed to help you use TalkingQuality to plan and manage your quality reporting project.
Share them with your team as you work through the process of planning and implementing your project.
Save the Word versions of these checklists to your computer so you…
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www.ahrq.gov/talkingquality/assess/why-evaluate.html
May 01, 2019 - Why Evaluate a Health Care Quality Reporting Project?
Just as report sponsors hope that health care providers and plans will use data on quality to improve their performance, you need to gather and use data to improve your reporting efforts over time. Experienced report sponsors approach their reporting initiat…
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psnet.ahrq.gov/node/40200/psn-pdf
July 02, 2014 - Checklists to reduce diagnostic errors.
July 2, 2014
Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med. 2011;86(3):307-313.
doi:10.1097/ACM.0b013e31820824cd.
https://psnet.ahrq.gov/issue/checklists-reduce-diagnostic-errors
Diagnostic errors are rapidly gaining attention as the next f…
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/video/cus-sbar-rural-clinic-guide.pdf
June 02, 2025 - TeamSTEPPS Video Debrief Guide: CUS and SBAR in Rural Community Clinic
TeamSTEPPS Video Debrief Guide: CUS and SBAR in Rural
Community Clinic
Video Objective
To demonstrate how CUS is used to ensure patient safety and showcase the SBAR communication
technique.
TeamSTEPPS Tool or Concept
CUS, SBAR.
Brief V…
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psnet.ahrq.gov/node/43308/psn-pdf
May 01, 2015 - An analysis of electronic health record–related patient
safety concerns.
May 1, 2015
Meeks DW, Smith MW, Taylor L, et al. An analysis of electronic health record-related patient safety
concerns. J Am Med Inform Assoc. 2014;21(6):1053-9. doi:10.1136/amiajnl-2013-002578.
https://psnet.ahrq.gov/issue/analysis-electro…
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psnet.ahrq.gov/node/45955/psn-pdf
January 01, 2021 - The essential role of leadership in developing a safety
culture.
April 3, 2017
The essential role of leadership in developing a safety culture. Sentinel Event Alert. 2021;57(57):1-8.
https://psnet.ahrq.gov/issue/essential-role-leadership-developing-safety-culture
The Joint Commission issues sentinel event alerts t…
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psnet.ahrq.gov/node/41795/psn-pdf
September 07, 2016 - Drug shortage-associated increase in catheter-related
blood stream infection in children.
September 7, 2016
Ralls MW, Blackwood A, Arnold MA, et al. Drug shortage-associated increase in catheter-related blood
stream infection in children. Pediatrics. 2012;130(5):e1369-73. doi:10.1542/peds.2011-3894.
https://psnet.…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/senior-checklist.html
July 01, 2023 - CEO/Senior Leader Checklist
AHRQ Safety Program for Perinatal Care
Who should use this tool: Senior leaders
Checklist Items
Leader Responsible
Date Initiated
1. Ensure all current and new employees receive Science of Safety training.
2. Assign a senior executive (C…
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psnet.ahrq.gov/node/44972/psn-pdf
February 15, 2017 - The effectiveness of electronic differential diagnoses
(DDX) generators: a systematic review and meta-analysis.
February 15, 2017
Riches N, Panagioti M, Alam R, et al. The Effectiveness of Electronic Differential Diagnoses (DDX)
Generators: A Systematic Review and Meta-Analysis. PLoS One. 2016;11(3):e0148991.
doi:…