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psnet.ahrq.gov/issue/paediatric-nurses-understanding-process-and-procedure-double-checking-medications
May 03, 2023 - Study
Paediatric nurses' understanding of the process and procedure of double-checking medications.
Citation Text:
Dickinson A, McCall E, Twomey B, et al. Paediatric nurses' understanding of the process and procedure of double-checking medications. J Clin Nurs. 2010;19(5-6). doi:10.111…
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psnet.ahrq.gov/issue/approach-assessing-patient-safety-hospitals-low-income-countries
July 22, 2020 - Study
An approach to assessing patient safety in hospitals in low-income countries.
Citation Text:
Lindfield R, Knight A, Bwonya D. An approach to assessing patient safety in hospitals in low-income countries. PLoS One. 2015;10(3):e0121628. doi:10.1371/journal.pone.0121628.
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psnet.ahrq.gov/issue/crossing-safety-transforming-healthcare-organizations-patient-safety
January 05, 2012 - Commentary
Crossing to safety: transforming healthcare organizations for patient safety.
Citation Text:
Ralston JD, Larson EB. Crossing to safety: transforming healthcare organizations for patient safety. J Postgrad Med. 2005;51(1):61-67.
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psnet.ahrq.gov/issue/creating-effective-quality-improvement-collaboratives-multiple-case-study
December 19, 2012 - Study
Creating effective quality-improvement collaboratives: a multiple case study.
Citation Text:
Strating MMH, Nieboer AP, Zuiderent-Jerak T, et al. Creating effective quality-improvement collaboratives: a multiple case study. BMJ Qual Saf. 2011;20(4). doi:10.1136/bmjqs.2010.047159. …
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psnet.ahrq.gov/issue/ethical-and-legal-issues-use-health-information-technology-improve-patient-safety
July 30, 2014 - Review
Ethical and legal issues in the use of health information technology to improve patient safety.
Citation Text:
Berner ES. Ethical and legal issues in the use of health information technology to improve patient safety. HEC Forum. 2008;20(3):243-58. doi:10.1007/s10730-008-9074-5. …
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psnet.ahrq.gov/issue/supervision-autonomy-and-medical-error-teaching-clinic
November 26, 2014 - Commentary
Supervision, autonomy, and medical error in the teaching clinic.
Citation Text:
Cossman JP, Wang M, Fischer AA. Supervision, autonomy, and medical error in the teaching clinic. J Am Acad Dermatol. 2018;79(5):981-983. doi:10.1016/j.jaad.2017.12.033.
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psnet.ahrq.gov/issue/patient-safety-helping-medical-students-understand-error-healthcare
December 16, 2009 - Study
Patient safety: helping medical students understand error in healthcare.
Citation Text:
Patey R, Flin R, Cuthbertson BH, et al. Patient safety: helping medical students understand error in healthcare. Qual Saf Health Care. 2007;16(4):256-9.
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psnet.ahrq.gov/issue/qualitative-study-examining-influences-situation-awareness-and-identification-mitigation-and
July 16, 2014 - Study
A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk.
Citation Text:
Brady PW, Goldenhar LM. A qualitative study examining the influences on situation awareness and the identification, miti…
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www.ahrq.gov/news/newsroom/case-studies/cquips1301.html
November 01, 2012 - Newman Memorial Hospital Implements AHRQ's Patient Safety Culture Survey
Search All Impact Case Studies
November 2012
Newman Memorial Hospital, a 79-bed acute hospital in Oklahoma, first implemented AHRQ's "Hospital Survey on Patient Safety Culture" in 2006, when concern about the hospital's patient safety …
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psnet.ahrq.gov/issue/identifying-cross-contaminants-and-specimen-mix-ups-surgical-pathology
July 22, 2020 - Review
Identifying cross contaminants and specimen mix-ups in surgical pathology.
Citation Text:
Hunt JL. Identifying cross contaminants and specimen mix-ups in surgical pathology. Adv Anat Pathol. 2008;15(4):211-7. doi:10.1097/PAP.0b013e31817bf596.
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psnet.ahrq.gov/issue/learning-samples-one-or-fewer
December 21, 2017 - Review
Classic
Learning from samples of one or fewer.
Citation Text:
Learning from samples of one or fewer. March JG, Sproull LS, Tamuz M. Org Sci.1991;2:1-13. (reprinted in: Qual Saf Health Care 2003;12:465-472.)
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psnet.ahrq.gov/issue/incidence-accidental-awareness-during-general-anaesthesia-obstetrics-multicentre-prospective
December 10, 2024 - Study
Emerging Classic
Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study.
Citation Text:
Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective coho…
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psnet.ahrq.gov/issue/investigating-improvement-five-strategies-ensure-national-patient-safety-investigations
February 28, 2024 - Commentary
Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety.
Citation Text:
Macrae C. Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety. J R Soc Med.…
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psnet.ahrq.gov/issue/zero-suicide-initiative
July 03, 2013 - Grant Announcement
Zero Suicide Initiative.
Citation Text:
Zero Suicide Initiative. Office of the Federal Register, National Archives and Records Administration. Fed Register. November 3, 2021;(86):60883-60893.
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www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/lessons.html
August 01, 2022 - Demonstration Grants Final Evaluation Report
Lessons Learned From Implementation Challenges
Previous Page Next Page
Table of Contents
Demonstration Grants Final Evaluation Report
Executive Summary
Detailed Findings
Evaluation Issues
Contributions to Patient Safety and Medical Liability
L…
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psnet.ahrq.gov/issue/creating-just-culture-ottawa-hospitals-experience
July 10, 2024 - Commentary
Creating a just culture: the Ottawa Hospital's experience.
Citation Text:
Forster AJ, Hamilton S, Hayes T, et al. Creating a Just Culture: The Ottawa Hospital's experience. Healthc Manage Forum. 2019;32(5):266-271. doi:10.1177/0840470419853303.
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psnet.ahrq.gov/issue/importance-failing-forward-all-us-will-fail-and-make-mistakes-how-can-they-benefit-us-and-our
July 27, 2016 - Newspaper/Magazine Article
The importance of failing forward. All of us will fail and make mistakes, but how can they benefit us and our organizations?
Citation Text:
Hofmann PB. The importance of failing forward. All of us will fail and make mistakes, but how can they benefit us and ou…
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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