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psnet.ahrq.gov/issue/evaluating-physician-performance-individualizing-care-pilot-study-tracking-contextual-errors
September 20, 2011 - Study
Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making.
Citation Text:
Weiner SJ, Schwartz A, Yudkowsky R, et al. Evaluating physician performance at individualizing care: a pilot study tracking contextual err…
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psnet.ahrq.gov/issue/preventing-patient-harms-through-systems-care
February 27, 2014 - Study
Preventing patient harms through systems of care.
Citation Text:
Pronovost P, Bo-Linn GW. Preventing patient harms through systems of care. JAMA. 2012;308(8):769-70. doi:10.1001/jama.2012.9537.
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psnet.ahrq.gov/issue/hret-patient-safety-leadership-fellowship-role-community-patient-safety
July 14, 2010 - Commentary
HRET Patient Safety Leadership Fellowship: The role of "community" in patient safety.
Citation Text:
Leonhardt KK. HRET Patient Safety Leadership Fellowship. Am J Med Qual. 2010;25(3):192-196. doi:10.1177/1062860609357469.
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psnet.ahrq.gov/issue/nhs-sticking-fingers-its-ears-humming-loudly
January 01, 2000 - Study
The NHS: sticking fingers in its ears, humming loudly.
Citation Text:
Pope R. The NHS: Sticking Fingers in Its Ears, Humming Loudly. J Bus Ethics. 2015;145(3):577-598. doi:10.1007/s10551-015-2861-4.
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psnet.ahrq.gov/issue/implementing-nurse-shadowing-program-first-year-medical-students-improve-interprofessional
January 15, 2025 - Commentary
Implementing a nurse-shadowing program for first-year medical students to improve interprofessional collaborations on health care teams.
Citation Text:
Jain A, Luo E, Yang J, et al. Implementing a nurse-shadowing program for first-year medical students to improve interprofessi…
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psnet.ahrq.gov/issue/development-and-implementation-hospital-based-patient-safety-program
June 21, 2006 - Commentary
Development and implementation of a hospital-based patient safety program.
Citation Text:
Frush K, Alton M, Frush DP. Development and implementation of a hospital-based patient safety program. Pediatr Radiol. 2006;36(4):291-8.
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psnet.ahrq.gov/issue/assessing-patient-safety-united-states-challenges-and-opportunities
July 07, 2021 - Review
Assessing patient safety in the United States: challenges and opportunities.
Citation Text:
Zhan C, Kelley E, Yang HP, et al. Assessing patient safety in the United States: challenges and opportunities. Med Care. 2005;43(3 Suppl):I42-I47.
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psnet.ahrq.gov/issue/implementing-bedside-handoff-emergency-department-practice-improvement-project
November 14, 2018 - Commentary
Implementing bedside handoff in the emergency department: a practice improvement project.
Citation Text:
Campbell D, Dontje K. Implementing Bedside Handoff in the Emergency Department: A Practice Improvement Project. J Emerg Nurs. 2019;45(2):149-154. doi:10.1016/j.jen.2018.09.…
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psnet.ahrq.gov/issue/wake-safe-and-root-cause-analysis-quality-improvement-pediatric-anesthesia
February 03, 2021 - Commentary
Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia.
Citation Text:
Tjia I, Rampersad S, Varughese AM, et al. Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. Anesth Analg. 2014;119(1):122-136. doi:10.1213/ANE.000…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20140115_DB/3_Deborah_Kilstein_slides_29-40.pdf
January 15, 2014 - Using the CAHPS Database to Compare, Report, and Improve Organizational Performance
CAHPS Sponsor Report
The ACAP Experience
Deborah Kilstein
ACAP Vice President, Quality Management and
Operational Support
January 15, 2014
29
Agenda
30
Who is ACAP?
Growing role of health plans
What …
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psnet.ahrq.gov/issue/characteristics-patients-misdiagnosed-alzheimers-disease-and-their-medication-use-analysis
June 16, 2011 - Study
Characteristics of patients misdiagnosed with Alzheimer's disease and their medication use: an analysis of the NACC-UDS database.
Citation Text:
Gaugler JE, Ascher-Svanum H, Roth DL, et al. Characteristics of patients misdiagnosed with Alzheimer's disease and their medication use:…
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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/implementing-smart-infusion-pumps-dose-error-reduction-software-real-world-experiences
May 26, 2021 - Commentary
Implementing smart infusion pumps with dose-error reduction software: real-world experiences.
Citation Text:
Heron C. Implementing smart infusion pumps with dose-error reduction software: real-world experiences. Br J Nurs. 2017;26(8):S13-S16. doi:10.12968/bjon.2017.26.8.S13.
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psnet.ahrq.gov/issue/impact-organizations-healthcare-associated-infections
December 11, 2024 - Commentary
Impact of organizations on healthcare-associated infections.
Citation Text:
Castro-Sánchez E, Holmes AH. Impact of organizations on healthcare-associated infections. J Hosp Infect. 2015;89(4):346-50. doi:10.1016/j.jhin.2015.01.012.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/nh-workplace-safety-ginsberg.pdf
January 01, 2015 - New AHRQ SOPS® Workplace Safety Supplemental Item Set for Nursing Homes - Caren Ginsberg, Ph.D.
5
AHRQ’s Surveys on Patient Safety Culture™
(SOPS®) Program
Caren Ginsberg, Ph.D.
Center for Quality Improvement and Patient Safety, AHRQ
6
Agency for Healthcare Research and Quality
• AHRQ is:
► A research and sci…
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psnet.ahrq.gov/issue/interruptions-wild-development-sociotechnical-systems-model-interruptions-emergency
August 31, 2016 - Review
Interruptions in the wild: development of a sociotechnical systems model of interruptions in the emergency department through a systematic review.
Citation Text:
Werner N, Holden RJ. Interruptions in the wild: Development of a sociotechnical systems model of interruptions in the e…
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psnet.ahrq.gov/issue/patient-safety-trauma-maximal-impact-management-errors-level-i-trauma-center
February 19, 2020 - Study
Patient safety in trauma: maximal impact management errors at a level I trauma center.
Citation Text:
Ivatury RR, Guilford K, Malhotra AK, et al. Patient safety in trauma: maximal impact management errors at a level I trauma center. J Trauma. 2008;64(2):265-270; discussion 270-27…
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psnet.ahrq.gov/issue/rules-and-guidelines-clinical-practice-qualitative-study-operating-theatres-doctors-and
January 06, 2018 - Study
Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views.
Citation Text:
McDonald R. Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views. Quality and Safety in…
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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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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-216-section-5-table-4.pdf
January 01, 2011 - Section 5, Table 4
Table 4: Evidence Supporting Appropriate Emergency Department Fever Management for Children
with Sickle Cell Disease
Type of
evidence
Key findings Level of
evidence
(USPSTF
ranking*)
Citation(s)
Clinical
guidelines
All children with SCD who have fever greater
than 38.5 degrees Cels…