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psnet.ahrq.gov/issue/necessity-pathway-high-alert-patients
July 14, 2010 - Commentary
Necessity for a pathway for "high-alert" patients.
Citation Text:
Shane R, Amer K, Noh L, et al. Necessity for a pathway for "high-alert" patients. Am J Health Syst Pharm. 2018;75(13):993-997. doi:10.2146/ajhp170397.
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psnet.ahrq.gov/issue/medication-reconciliation-qualitative-analysis-clinicians-perceptions
October 10, 2015 - Study
Medication reconciliation: a qualitative analysis of clinicians' perceptions.
Citation Text:
Vogelsmeier A, Pepper GA, Oderda L, et al. Medication reconciliation: A qualitative analysis of clinicians' perceptions. Res Social Adm Pharm. 2013;9(4):419-30. doi:10.1016/j.sapharm.201…
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psnet.ahrq.gov/issue/obstetric-medical-emergency-teams-are-step-forward-maternal-safety
November 04, 2020 - Review
Obstetric medical emergency teams are a step forward in maternal safety!
Citation Text:
Al Kadri HMF. Obstetric medical emergency teams are a step forward in maternal safety!. J Emerg Trauma Shock. 2010;3(4):337-341. doi:10.4103/0974-2700.70755.
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psnet.ahrq.gov/issue/near-misses-paradoxical-realities-everyday-clinical-practice
May 04, 2012 - Study
Near misses: paradoxical realities in everyday clinical practice.
Citation Text:
Jeffs L, Affonso DD, Macmillan K. Near misses: paradoxical realities in everyday clinical practice. Int J Nurs Pract. 2008;14(6):486-94. doi:10.1111/j.1440-172X.2008.00724.x.
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psnet.ahrq.gov/issue/using-ora-explore-relationship-nursing-unit-communication-patient-safety-and-quality-outcomes
December 11, 2008 - Study
Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes.
Citation Text:
Effken JA, Carley KM, Gephart SM, et al. Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes. Int J Me…
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psnet.ahrq.gov/node/33620/psn-pdf
September 01, 2005 - In response to “Getting to the Root of the Matter” (June
2005)
September 1, 2005
Grondin L, Saint S, Flanders S, et al. In response to “Getting to the Root of the Matter” (June 2005). PSNet
[internet]. 2005.
https://psnet.ahrq.gov/perspective/response-getting-root-matter-june-2005
In response to "Getting to the R…
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psnet.ahrq.gov/issue/investigating-causes-adverse-events
October 03, 2017 - Commentary
Investigating the causes of adverse events.
Citation Text:
Sanchez JA, Lobdell KW, Moffatt-Bruce SD, et al. Investigating the Causes of Adverse Events. Ann Thorac Surg. 2017;103(6):1693-1699. doi:10.1016/j.athoracsur.2017.04.001.
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psnet.ahrq.gov/issue/impact-care-quality-commission-provider-performance-room-improvement
November 18, 2015 - Book/Report
Impact of the Care Quality Commission on Provider Performance: Room for Improvement?
Citation Text:
Impact of the Care Quality Commission on Provider Performance: Room for Improvement? Smithson R, Richardson E, Roberts J, et al. The King's Fund, Alliance Manchester Business S…
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psnet.ahrq.gov/issue/effect-acgme-duty-hours-attending-physician-teaching-and-satisfaction
February 17, 2009 - Study
Effect of ACGME duty hours on attending physician teaching and satisfaction.
Citation Text:
Arora V, Meltzer DO. Effect of ACGME duty hours on attending physician teaching and satisfaction. Arch Intern Med. 2008;168(11):1226-8. doi:10.1001/archinte.168.11.1226.
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psnet.ahrq.gov/issue/pharmacist-physician-relationship-detection-ambulatory-medication-errors
September 30, 2020 - Study
The pharmacist-physician relationship in the detection of ambulatory medication errors.
Citation Text:
Brown A, Bailey JH, Lee J, et al. The pharmacist-physician relationship in the detection of ambulatory medication errors. Am J Med Sci. 2006;331(1):22-24.
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psnet.ahrq.gov/issue/eradicating-medical-student-mistreatment-longitudinal-study-one-institutions-efforts
August 28, 2019 - Study
Eradicating medical student mistreatment: a longitudinal study of one institution's efforts.
Citation Text:
Fried JM, Vermillion M, Parker NH, et al. Eradicating medical student mistreatment: a longitudinal study of one institution's efforts. Acad Med. 2012;87(9):1191-1198.
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psnet.ahrq.gov/issue/insights-climate-safety-towards-prevention-falls-among-hospital-staff
February 14, 2017 - Study
Insights into the climate of safety towards the prevention of falls among hospital staff.
Citation Text:
Black AA, Brauer SG, Bell RAR, et al. Insights into the climate of safety towards the prevention of falls among hospital staff. J Clin Nurs. 2011;20(19-20):2924-30. doi:10.111…
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psnet.ahrq.gov/issue/health-care-quality-and-disparities-lessons-first-national-reports
April 03, 2005 - Special or Theme Issue
Health Care Quality and Disparities: Lessons from the First National Reports.
Citation Text:
Health Care Quality and Disparities: Lessons from the First National Reports. Kelley E, Moy E, Dayton E, et al. Med Care. 2005:43(3):I1-I88.
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psnet.ahrq.gov/issue/handovers-or-icu
January 03, 2017 - Commentary
Handovers from the OR to the ICU.
Citation Text:
Bonifacio AS, Segall N, Barbeito A, et al. Handovers from the OR to the ICU. Int Anesthesiol Clin. 2013;51(1):43-61. doi:10.1097/AIA.0b013e31826f2b0e.
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psnet.ahrq.gov/issue/accountability-organisational-learning-and-risks-patient-safety-england-conflict-or
December 29, 2014 - Commentary
Accountability, organisational learning and risks to patient safety in England: conflict or compromise?
Citation Text:
Dodds A, Kodate N. Accountability, organisational learning and risks to patient safety in England: Conflict or compromise? Health Risk Soc. 2011;13(4):327-3…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-model-pdsa.pdf
June 02, 2025 - Job Aid: Model for Improvement and PDSA Cycles
Primary Care Practice Facilitator
Training Series
1
Job Aid: Model for Improvement and PDSA Cycles
Using the Model for Improvement
The Model for Improvement (MFI) is a simple framework that many primary care practices use
to help them organize their i…
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psnet.ahrq.gov/issue/getting-boards-board-engaging-governing-boards-quality-and-safety
February 17, 2017 - Commentary
Getting boards on board: engaging governing boards in quality and safety.
Citation Text:
Conway JB. Getting boards on board: engaging governing boards in quality and safety. Jt Comm J Qual Saf. 2008;34(4):214-220.
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digital.ahrq.gov/sites/default/files/docs/page/buildinghealthitresearchcapacity.pdf
December 01, 2012 - This includes supporting the next generation of
health IT researchers by funding health IT-focused … The
SEN noted particular interest in funding disserta-
tion research projects focused in one of three … Portfolio has supported six doctoral
candidates from a range of disciplines working on
health IT-focused … Analyses
focused on patient characteristics such as age, gender,
and race; hospital characteristics … A variety of additional health IT-focused dissertation
grants are currently ongoing and will continue
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024350-wernz-final-report-2018.pdf
January 01, 2018 - A study focused on small private practices estimates
that downtime costs are approximately $500 per … Few studies have focused on the impact of delays
in reporting of results, and even fewer studies have … We focused on door-to-doc time,
patient backlog, and arrival rate. … ED interviews
focused on physicians and nurses; laboratory sessions focused on technicians from the … The interviews focused on feedback from stakeholders
about their perceptions of downtime operations,
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs023849-valdez-final-report-2018.pdf
January 01, 2018 - Consumer health IT developers, however, have
predominantly focused on the needs of a limited number … (15)
Context: This study focused on complementing and building upon existing design guidance from … The study focused on one form
(i.e., mobile health) and one functional domain (i.e., health information … Phase two focused on participants’ experiences engaging with the three mHealth
apps both in a lab (task … In particular, this study
focused on one form and one functional domain of consumer health IT, mHealth