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psnet.ahrq.gov/issue/variation-hospital-mortality-associated-inpatient-surgery
August 02, 2015 - Study
Classic
Variation in hospital mortality associated with inpatient surgery.
Citation Text:
Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361(14):1368-75. doi:10.1056/NEJMsa090304…
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psnet.ahrq.gov/issue/teamwork-obstetric-critical-care
January 31, 2024 - Review
Teamwork in obstetric critical care.
Citation Text:
Guise J-M, Segel S. Teamwork in obstetric critical care. Best Pract Res Clin Obstet Gynaecol. 2008;22(5):937-51. doi:10.1016/j.bpobgyn.2008.06.010.
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psnet.ahrq.gov/issue/flow-accuracy-iv-smart-pumps-outside-patient-rooms-during-covid-19
October 12, 2022 - Commentary
Flow accuracy of IV smart pumps outside of patient rooms during COVID-19.
Citation Text:
Blake JWC, Giuliano KK. Flow accuracy of IV smart pumps outside of patient rooms during COVID-19. AACN Adv Crit Care. 2020;31(4):357-363. doi:10.4037/aacnacc2020241.
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psnet.ahrq.gov/issue/effects-bar-coding-technology-medication-errors-systematic-literature-review
March 20, 2024 - Review
The effects of bar-coding technology on medication errors: a systematic literature review.
Citation Text:
Hutton K, Ding Q, Wellman G. The Effects of Bar-coding Technology on Medication Errors: A Systematic Literature Review. J Patient Saf. 2021;17(3):e192-e206. doi:10.1097/PTS.00…
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psnet.ahrq.gov/issue/possible-solutions-barriers-incident-reporting-residents
April 14, 2011 - Study
Possible solutions for barriers in incident reporting by residents.
Citation Text:
Martowirono K, Jansma JD, van Luijk SJ, et al. Possible solutions for barriers in incident reporting by residents. J Eval Clin Pract. 2012;18(1):76-81. doi:10.1111/j.1365-2753.2010.01544.x.
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psnet.ahrq.gov/issue/nurses-experiences-drug-administration-errors
October 14, 2020 - Study
Nurses' experiences of drug administration errors.
Citation Text:
Schelbred A-B, Nord R. Nurses' experiences of drug administration errors. J Adv Nurs. 2007;60(3):317-24.
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www.ahrq.gov/sites/default/files/publications/files/system-design_0.pdf
July 01, 2011 - Designing Consumer Reporting Systems for Patient Safety Events: Project Overview
Advancing Excellence in Health Care • www.ahrq.gov
Agency for Healthcare Research and Quality PATIENT
SAFETY
Designing Consumer Reporting
Systems for Patient Safety Events
Background
It’s been nearly a decade since the Institute of
M…
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psnet.ahrq.gov/issue/predictors-completeness-patients-self-reported-personal-medication-lists-and-discrepancies
October 19, 2022 - Study
Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists.
Citation Text:
Lee KP, Nishimura K, Ngu B, et al. Predictors of completeness of patients' self-reported personal medication lists and discrepancies with…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/study.html
May 01, 2017 - Appendix K. Quality Improvement Study Framework - Implementation Guide
Study Elements
Element
Definition
Things To Keep in Mind
The Purpose
Define the problem and why it is important.
Avoid suggesting causes in the purpose statement. Cause determination will come later afte…
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psnet.ahrq.gov/issue/using-learning-communities-support-adoption-health-care-innovations
March 15, 2017 - Commentary
Using learning communities to support adoption of health care innovations.
Citation Text:
Carpenter D, Hassell S, Mardon R, et al. Using Learning Communities to Support Adoption of Health Care Innovations. Jt Comm J Qual Patient Saf. 2018;44(10):566-573. doi:10.1016/j.jcjq.201…
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psnet.ahrq.gov/issue/sins-omission-getting-too-little-medical-care-may-be-greatest-threat-patient-safety
March 06, 2005 - Study
Sins of omission. Getting too little medical care may be the greatest threat to patient safety.
Citation Text:
Hayward RA, Asch SM, Hogan MM, et al. Sins of omission: getting too little medical care may be the greatest threat to patient safety. J Gen Intern Med. 2005;20(8):686-91…
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psnet.ahrq.gov/issue/perception-feeling-safe-perioperatively-concept-analysis
December 21, 2022 - Review
Perception of feeling safe perioperatively: a concept analysis.
Citation Text:
Larsson F, Strömbäck U, Rysst Gustafsson S, et al. Perception of feeling safe perioperatively: a concept analysis. Int J Qual Stud Health Well-being. 2023;18(1):2216018. doi:10.1080/17482631.2023.221601…
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psnet.ahrq.gov/issue/call-action-addressing-pediatric-fall-safety-ambulatory-environments
June 30, 2021 - Study
Call to action: addressing pediatric fall safety in ambulatory environments.
Citation Text:
Benning S, Wolfe R, Banes M, et al. Call to action: addressing pediatric fall safety in ambulatory environments. J Pediatr Nurs. 2021;61:372-377. doi:10.1016/j.pedn.2021.09.012.
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www.ahrq.gov/topics/emergency-department.html
October 01, 2024 - Emergency Department
AHRQ's resources on emergency departments (EDs) include research studies, data and analytics, and tools designed to improve patient safety and the delivery of care. Topics explored include ED boarding and crowding, infection prevention, and diagnostic safety.
Eme…
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psnet.ahrq.gov/issue/learning-errors-and-resilience
December 18, 2019 - Review
Learning from errors and resilience.
Citation Text:
Arnal-Velasco D, Heras-Hernando V. Learning from errors and resilience. Curr Opin Anaesthesiol. 2023;36(3):376-381. doi:10.1097/aco.0000000000001257.
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psnet.ahrq.gov/issue/health-technology-quality-and-safety-learning-health-system
February 09, 2022 - Commentary
Health technology, quality and safety in a learning health system.
Citation Text:
Borycki EM, Kushniruk AW. Health technology, quality and safety in a learning health system. Healthc Manage Forum. 2023;51(2):212-221. doi:10.1177/08404704221139383.
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psnet.ahrq.gov/issue/new-diagnostic-team
July 19, 2023 - Commentary
The new diagnostic team.
Citation Text:
Graber ML, Rusz D, Jones ML, et al. The new diagnostic team. Diagnosis (Berl). 2017;4(4):225-238. doi:10.1515/dx-2017-0022.
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psnet.ahrq.gov/issue/organisational-reporting-and-learning-systems-innovating-inside-and-outside-box
July 22, 2020 - Commentary
Organisational reporting and learning systems: innovating inside and outside of the box.
Citation Text:
Sujan M, Furniss D. Organisational reporting and learning systems: Innovating inside and outside of the box. Clin Risk. 2015;21(1):7-12. doi:10.1177/1356262215574203.
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integrationacademy.ahrq.gov/news-and-events/news/nofo-released-innovation-behavioral-health-model
July 22, 2024 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
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psnet.ahrq.gov/issue/improving-diagnosis-health-care
September 12, 2018 - Book/Report
Classic
Improving Diagnosis in Health Care.
Citation Text:
Improving Diagnosis in Health Care. Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015. ISB…