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www.ahrq.gov/news/events/nac/2017-11-nac/nacmtg1117-minutes.html
February 01, 2018 - Its data helped to inform creation of the new ICD-10 coding system, transitioning from ICD-9.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/children-special-needs-transition_disposition-comments.pdf
June 17, 2014 - primary care and adult specialty care, while perhaps present
among the key informants, might have helped
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psnet.ahrq.gov/node/47262/psn-pdf
August 22, 2018 - The Case for Medication Safety Officers (MSO).
August 22, 2018
Horsham, PA: Institute for Safe Medication Practices; 2018.
https://psnet.ahrq.gov/issue/case-medication-safety-officers-mso
Medication safety is a concern in various settings across an organization. This white paper discusses the
role of a medication …
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psnet.ahrq.gov/node/34114/psn-pdf
September 20, 2023 - Speak Up Initiative.
September 20, 2023
Joint Commission.
https://psnet.ahrq.gov/issue/speak-initiative
The Speak Up campaign provides sets of materials to enable patients and families to engage in making
their health care experiences as safe as possible. Topics covered include safe surgery, pain management,
medi…
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www.ahrq.gov/ncepcr/tools/transform-qi/facilitation/heart-health-toolkit.html
April 01, 2021 - Primary Care Quality Improvement (QI) Toolkit for Heart Health
Resource: Implementing Heart Health Practice Self-Assessment
This toolkit is for facilitators to help primary care practices implement the ABCS of heart health and create a supportive practice environment for quality improvement. It contains 1…
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psnet.ahrq.gov/node/39539/psn-pdf
January 13, 2013 - We need leaders: the 48th Annual Rovenstine Lecture.
January 13, 2013
Pronovost P. We need leaders: The 48th Annual Rovenstine Lecture. Anesthesiology. 2010;112(4):779-
785. doi:10.1097/ALN.0b013e3181d32047.
https://psnet.ahrq.gov/issue/we-need-leaders-48th-annual-rovenstine-lecture
Dr. Pronovost provides a histor…
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psnet.ahrq.gov/node/844756/psn-pdf
September 18, 2019 - Emerging Concepts in Patient Safety.
September 18, 2019
Shapiro FE, ed. Int Anesthesiol Clin. 2019;57:1-162.
https://psnet.ahrq.gov/issue/emerging-concepts-patient-safety
This publication presents patient safety concepts for anesthesia practice, including decision aids to educate
and empower patients about anesthe…
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psnet.ahrq.gov/node/45840/psn-pdf
February 08, 2017 - Implementation of the safety huddle.
February 8, 2017
Kylor C, Napier T, Rephann A, et al. Implementation of the Safety Huddle. Crit Care Nurse. 2016;36(6):80-
82.
https://psnet.ahrq.gov/issue/implementation-safety-huddle
The safety huddle is becoming common within health care practice as a way to inform clinician…
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psnet.ahrq.gov/node/46500/psn-pdf
June 27, 2018 - Ariadne Labs.
June 27, 2018
Brigham & Women's Hospital; Harvard T.H. Chan School of Public Health.
https://psnet.ahrq.gov/issue/ariadne-labs
Checklists can help catch gaps in communication and process. This website provides resources related to
the use of checklists in surgical, obstetric, and other care environme…
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psnet.ahrq.gov/node/41578/psn-pdf
October 09, 2013 - Improving Patient Safety in Long-Term Care Facilities:
Training Modules.
October 9, 2013
Taylor SL, Saliba D. Rockville, MD: Agency for Healthcare Research and Quality; July 2012. AHRQ
Publication No. 12-0001.
https://psnet.ahrq.gov/issue/improving-patient-safety-long-term-care-facilities-training-modules
This se…
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psnet.ahrq.gov/node/45741/psn-pdf
November 16, 2018 - Monitoring the diagnostic process on an inpatient
neurology service.
November 16, 2018
Dhand A, Bucelli R, Varadhachary A, et al. Monitoring the Diagnostic Process on an Inpatient Neurology
Service. Neurohospitalist. 2017;7(3):132-136. doi:10.1177/1941874416677681.
https://psnet.ahrq.gov/issue/monitoring-diagnosti…
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psnet.ahrq.gov/node/36914/psn-pdf
March 21, 2017 - Reasons for after-hours calls by hospital floor nurses to
on-call physicians.
March 21, 2017
Bernstam E, Pancheri KK, Johnson CM, et al. Reasons for after-hours calls by hospital floor nurses to on-
call physicians. Jt Comm J Qual Patient Saf. 2007;33(6):342-9.
https://psnet.ahrq.gov/issue/reasons-after-hours-call…
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psnet.ahrq.gov/node/42357/psn-pdf
December 04, 2016 - Disclosing medical mistakes: a communication
management plan for physicians.
December 4, 2016
Petronio S, Torke A, Bosslet G, et al. Disclosing medical mistakes: a communication management plan for
physicians. Perm J. 2013;17(2):73-9. doi:10.7812/TPP/12-106.
https://psnet.ahrq.gov/issue/disclosing-medical-mistakes…
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psnet.ahrq.gov/node/45047/psn-pdf
April 13, 2016 - Is misdiagnosis inevitable?
April 13, 2016
Page L. Medscape Business of Medicine. March 28, 2016.
https://psnet.ahrq.gov/issue/misdiagnosis-inevitable
This news article reports on the prevalence of diagnostic error and describes characteristics that contribute
to the problem, including insufficient clinician famil…
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psnet.ahrq.gov/node/38685/psn-pdf
August 18, 2010 - HomeNet: ensuring patient safety with medical device use
in the home.
August 18, 2010
Kaufman D, Weick-Brady M. HomeNet: ensuring patient safety with medical device use in the home. Home
Healthc Nurse. 2009;27(5):300-7.
https://psnet.ahrq.gov/issue/homenet-ensuring-patient-safety-medical-device-use-home
This arti…
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psnet.ahrq.gov/node/35480/psn-pdf
February 22, 2010 - Involuntary automaticity: a work-system induced risk to
safe health care.
February 22, 2010
Toft B, Mascie-Taylor H. Involuntary automaticity: a work-system induced risk to safe health care. Health
Serv Manage Res. 2005;18(4):211-6.
https://psnet.ahrq.gov/issue/involuntary-automaticity-work-system-induced-risk-saf…
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psnet.ahrq.gov/node/38358/psn-pdf
September 12, 2016 - Failure to rescue as a process measure to evaluate fetal
safety during labor.
September 12, 2016
Beaulieu MJ. Failure to rescue as a process measure to evaluate fetal safety during labor. MCN Am J
Matern Child Nurs. 2009;34(1):18-23. doi:10.1097/01.NMC.0000343861.64614.c9.
https://psnet.ahrq.gov/issue/failure-resc…
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psnet.ahrq.gov/node/844753/psn-pdf
September 18, 2019 - Detecting medication administration errors.
September 18, 2019
Durham ML, Jankiewicz A. Detecting Medication Administration Errors. J Patient Saf. 2019;15(3):181-183.
doi:10.1097/PTS.0000000000000384.
https://psnet.ahrq.gov/issue/detecting-medication-administration-errors
Considerable effort has been devoted to op…
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psnet.ahrq.gov/node/42227/psn-pdf
April 24, 2013 - Medication errors in nursing—part 1 and part 2.
April 24, 2013
Leufer T, Cleary-Holdforth J. Let's do no harm: medication errors in nursing: part 1. Nurse Educ Pract.
2013;13(3):213-216. doi:10.1016/j.nepr.2013.01.013.
https://psnet.ahrq.gov/issue/medication-errors-nursing-part-1-and-part-2
This two-part commentar…
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psnet.ahrq.gov/node/44693/psn-pdf
June 15, 2016 - Safety.
June 15, 2016
Center for Health Design.
https://psnet.ahrq.gov/issue/safety-0
Elements of the health care work environment can affect the care delivery. This website highlights design
considerations for health care facilities that can help reduce noise, falls, and hospital-acquired infections.
The collect…