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psnet.ahrq.gov/issue/framework-engaging-physicians-quality-and-safety
July 10, 2008 - Study
Classic
A framework for engaging physicians in quality and safety.
Citation Text:
Taitz JM, Lee TH, Sequist TD. A framework for engaging physicians in quality and safety. BMJ Qual Saf. 2012;21(9):722-728. doi:10.1136/bmjqs-2011-000167.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-sustainability-centers-of-excellence5.html
April 01, 2025 - Four Pillars for Sustainable Centers of Excellence
Leadership Support
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Table of Contents
Four Pillars for Sustainable Centers of Excellence
Introduction
Center of Excellence Operations
Alignment
Integration
Leadership Support
Windows of Opportunity
Conclusion
A…
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psnet.ahrq.gov/issue/effects-team-based-assessment-and-intervention-patient-safety-culture-general-practice-open
August 14, 2013 - Study
Effects of a team-based assessment and intervention on patient safety culture in general practice: an open randomised controlled trial.
Citation Text:
Hoffmann B, Müller V, Rochon J, et al. Effects of a team-based assessment and intervention on patient safety culture in general p…
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psnet.ahrq.gov/issue/psychiatry-morbidity-and-mortality-incident-reporting-tool-increases-psychiatrist
March 10, 2021 - Study
The Psychiatry Morbidity and Mortality Incident Reporting Tool increases psychiatrist participation in reporting adverse events.
Citation Text:
Kroll DS, Shellman AD, Gitlin DF. The Psychiatry Morbidity and Mortality Incident Reporting Tool Increases Psychiatrist Participation in R…
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psnet.ahrq.gov/issue/factors-influencing-incident-reporting-surgical-care
March 03, 2011 - Study
Factors influencing incident reporting in surgical care.
Citation Text:
Kreckler S, Catchpole K, McCulloch P, et al. Factors influencing incident reporting in surgical care. Qual Saf Health Care. 2009;18(2):116-20. doi:10.1136/qshc.2008.026534.
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psnet.ahrq.gov/issue/improved-pain-resolution-hospitalized-patients-through-targeting-pain-mismanagement-medical
March 24, 2019 - Study
Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error.
Citation Text:
Okon TR, Lutz PS, Liang H. Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error. J Pain Symptom Manage.…
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psnet.ahrq.gov/issue/relationship-between-performance-measurement-and-accreditation-implications-quality-care-and
March 13, 2013 - Study
Relationship between performance measurement and accreditation: implications for quality of care and patient safety.
Citation Text:
Miller MR, Pronovost P, Donithan M, et al. Relationship between performance measurement and accreditation: implications for quality of care and pati…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-2-presentation.pdf
May 01, 2007 - Just Culture Webcast Presentation
University of North Carolina Health System
13
Celeste Mayer, PhD
University of North Carolina Health Care
System, Chapel Hill, NC
UNC Medical Center
• Public Academic Medical Center
• Memorial, Children’s, Neurosciences, Women’s and
Cancer Hospital
• ~850 beds
• Chapel Hill, N…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-creative-strategies-lee.pdf
June 02, 2025 - Creative Strategies to Improve Patient Care Experience - Part 4 Lee
What Is A Creative Idea?
Creative idea: An idea that is novel and useful
Creative
Improvement
Ideas
Process
Improvement
Promoting efficiency
by tweaking existing
routines
Patient Engagement
Enhancing patient
partnership by
knowing…
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psnet.ahrq.gov/issue/incidence-adverse-events-integrated-us-healthcare-system-retrospective-observational-study
April 08, 2011 - Study
Incidence of adverse events in an integrated US healthcare system: a retrospective observational study of 82,784 surgical hospitalizations.
Citation Text:
Zeeshan MF, Dembe AE, Seiber EE, et al. Incidence of adverse events in an integrated US healthcare system: a retrospective obse…
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psnet.ahrq.gov/issue/differential-perceptions-what-constitutes-medical-error-associated-electronic-medical-records
August 09, 2023 - Commentary
Differential perceptions of what constitutes a medical error associated with electronic medical records.
Citation Text:
Koppel R, Kuziemsky C, Elkin PL, et al. Differential perceptions of what constitutes a medical error associated with electronic medical records. Stud Health …
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psnet.ahrq.gov/issue/prevalence-and-factors-associated-patient-nondisclosure-medically-relevant-information
May 31, 2017 - Study
Emerging Classic
Prevalence of and factors associated with patient nondisclosure of medically relevant information to clinicians.
Citation Text:
Levy AG, Scherer AM, Zikmund-Fisher BJ, et al. Prevalence of and Factors Associated With Patient Nondisclosure …
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psnet.ahrq.gov/issue/starting-elective-cardiac-surgery-after-3-pm-does-not-impact-patient-morbidity-mortality-or
February 12, 2020 - Study
Starting elective cardiac surgery after 3 pm does not impact patient morbidity, mortality, or hospital costs.
Citation Text:
Axtell AL, Moonsamy P, Melnitchouk S, et al. Starting elective cardiac surgery after 3 pm does not impact patient morbidity, mortality, or hospital costs. J …
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psnet.ahrq.gov/issue/qualitative-study-why-general-practitioners-may-participate-significant-event-analysis-and
October 29, 2008 - Study
A qualitative study of why general practitioners may participate in significant event analysis and educational peer assessment.
Citation Text:
Bowie P, McKay J, Dalgetty E, et al. A qualitative study of why general practitioners may participate in significant event analysis and e…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.docx
January 01, 2010 - Strategy 4: IDEA Discharge Planning (Tool 3)
Strategy 4: IDEAL Discharge Planning (Tool 3)
Improving Discharge Outcomes with Patients and Families
Strategy 1: Working with Patients & Families as Advisors
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Strategy 4: IDEAL Discharge Planning (Tool 3)
O Guide to Patient and Family …
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psnet.ahrq.gov/issue/radiology-errors-are-we-learning-our-mistakes
May 26, 2011 - Study
Radiology errors: are we learning from our mistakes?
Citation Text:
Mankad K, Hoey ETD, Jones JB, et al. Radiology errors: are we learning from our mistakes? Clin Radiol. 2009;64(10):988-93. doi:10.1016/j.crad.2009.06.002.
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www.ahrq.gov/hai/pfp/interimhac2013-ap4.html
December 01, 2014 - Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms
Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013
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Table of Contents
Efforts To Improve Patient Safety Result in 1.3 Mill…
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psnet.ahrq.gov/issue/reducing-near-miss-medication-events-using-evidence-based-approach
July 07, 2021 - Study
Reducing near miss medication events using an evidence-based approach.
Citation Text:
Smith-Love J. Reducing near miss medication events using an evidence-based approach. J Nurs Care Qual. 2022;37(4):327-333. doi:10.1097/ncq.0000000000000630.
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www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guidesum.html
March 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism
Executive Summary
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Table of Contents
Preventing Hospital-Associated Venous Thromboembolism
Preface
Executive Summary
Chapter 1. The Framework for Improvement
Chapter 2. Analyze Care Delivery
Chapter 3. Outline the…
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psnet.ahrq.gov/issue/prevalence-error-prone-abbreviations-used-medication-prescribing-hospitalised-patients-multi
July 06, 2011 - Study
Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital evaluation.
Citation Text:
Dooley MJ, Wiseman M, Gu G. Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital …