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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…
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psnet.ahrq.gov/node/33630/psn-pdf
March 01, 2006 - Team Training: Classroom Training vs. High-Fidelity
Simulation
March 1, 2006
Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulation. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
Point–Counterpoint
Editor's Note…
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psnet.ahrq.gov/node/33629/psn-pdf
March 01, 2006 - What Does Simulation Add to Teamwork Training?
March 1, 2006
Gaba DM. What Does Simulation Add to Teamwork Training? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training
Editor's Note: In these point–counterpoint articles, Drs. Pratt and Sachs of Beth Israel Deacones…
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - Detection of Safety Hazards
September 15, 2024
Detection of Safety Hazards. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/detection-safety-hazards
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient s…
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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - Detection of Safety Hazards
Citation Text:
Detection of Safety Hazards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/individual-clinician-performance-issues
March 15, 2025 - Individual Clinician Performance Issues
Citation Text:
Individual Clinician Performance Issues. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/engaging-and-educating
January 01, 2024 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
Contact Us
Español
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The Academy
Integrating Behavioral Health & Primary Care
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Patient Safety 101
June 16, 2024
Patient Safety 101. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-safety-101
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in…
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www.ahrq.gov/ncepcr/tools/public-reporting/guide3.html
June 01, 2017 - Best Practices in Public Reporting No. 3: How to Maximize Public Awareness and Use of Comparative Quality Reports Through Effective Promotion and Dissemination Strategies
The purpose of the Best Practices in Public Reporting series is to provide practical approaches to designing public reports that make health …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/public-reporting/report-3-public-reporting.pdf
June 01, 2010 - Best Practices in Public Reporting No. 3: How to Maximize Public Awareness and Use of Comparative Quality Reports Through Effective Promotion and Dissemination Strategies
Best Practices in Public Reporting No. 3: How to
Maximize Public Awareness and Use of Comparative
Quality Reports Through Effective Promotion an…
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digital.ahrq.gov/sites/default/files/docs/TRANSCRIPT%20OF%20LEVERAGING%20HEALTH%20INFORMATION%20TECHNOLOGY%20FOR%20PATIENT%20EMPOWERMENT_1.pdf
April 08, 2010 - So can you talk a little bit
about your experiences working with the industry or in developing the systems
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psnet.ahrq.gov/node/47674/psn-pdf
December 19, 2018 - Patient safety after implementation of a coproduced
family centered communication programme: multicenter
before and after intervention study.
December 19, 2018
Khan A, Spector ND, Baird JD, et al. Patient safety after implementation of a coproduced family centered
communication programme: multicenter before and af…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/murphy-diagram
January 01, 2023 - Murphy Diagram
Description
Murphy diagrams are based on the premise that "if something can go wrong, it will go wrong." They are similar to other analysis methods such as fault trees as they analyze errors based on the potential causes of those errors. The diagrams utilize eight categories of behav…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/balanced-scorecard
January 01, 2023 - Balanced Scorecard
Description
A balanced scorecard provides a way to look at an organization from four perspectives by developing benchmarks and collecting and analyzing data relative to those perspectives. The four perspectives are: 1) financial, 2) customer, 3) internal business processes, an…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/pert-chart
January 01, 2023 - Program Evaluation and Review Technique Chart
Acronym
PERT
Also Known As
PERT Chart
Description
Program evaluation and review technique (PERT) charts are useful when managing a project. It is used to streamline project planning and scheduling. The method is particularly useful when…
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digital.ahrq.gov/ahrq-funded-projects/holomua-project-improving-patient-hand-offs-hawaii
January 01, 2023 - Holomua Project-Improving Patient Hand-Offs in Hawaii
Project Description
Project Details -
Completed
Grant Number
P20 HS015248
Funding Mechanism(s)
Transforming Healthcare Quality Through Information Technology (THQIT) - Planning Grant…
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psnet.ahrq.gov/issue/preventing-accidents-and-injuries-mri-suite
July 18, 2024 - Press Release/Announcement
Preventing accidents and injuries in the MRI suite.
Citation Text:
Preventing accidents and injuries in the MRI suite. Sentinel Event Alert. 2008;38(38):1-3.
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psnet.ahrq.gov/node/39084/psn-pdf
March 05, 2010 - The impact of Rapid Response System on delayed
emergency team activation patient characteristics and
outcomes—a follow-up study.
March 5, 2010
Calzavacca P, Licari E, Tee A, et al. The impact of Rapid Response System on delayed emergency team
activation patient characteristics and outcomes--a follow-up study. Resu…
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psnet.ahrq.gov/node/41223/psn-pdf
March 21, 2012 - High-profile investigations into hospital safety problems
in England did not prompt patients to switch providers.
March 21, 2012
Laverty AA, Smith PC, Pape UJ, et al. High-profile investigations into hospital safety problems in England
did not prompt patients to switch providers. Health Aff (Millwood). 2012;31(3):5…
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psnet.ahrq.gov/node/47082/psn-pdf
July 02, 2019 - Effect of systematic physician cross-checking on
reducing adverse events in the emergency department:
the CHARMED cluster randomized trial.
July 2, 2019
Freund Y, Goulet H, Leblanc J, et al. Effect of Systematic Physician Cross-checking on Reducing Adverse
Events in the Emergency Department: The CHARMED Cluster Ra…