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psnet.ahrq.gov/node/46933/psn-pdf
April 04, 2018 - Pain states, the opioid epidemic, and the role of
radiologists.
April 4, 2018
Jones MR, Kaye AD, Manchikanti L, et al. Pain States, the Opioid Epidemic, and the Role of Radiologists.
Curr Pain Headache Rep. 2018;22(3):20. doi:10.1007/s11916-018-0672-x.
https://psnet.ahrq.gov/issue/pain-states-opioid-epidemic-and-r…
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psnet.ahrq.gov/node/43182/psn-pdf
May 14, 2014 - Quality and safety in pediatric anesthesia: how can
guidelines, checklists, and initiatives improve the
outcome?
May 14, 2014
Hagerman NS, Varughese AM, Kurth D. Quality and safety in pediatric anesthesia: how can guidelines,
checklists, and initiatives improve the outcome? Curr Opin Anaesthesiol. 2014;27(3):323-9…
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psnet.ahrq.gov/node/45670/psn-pdf
November 16, 2016 - Not thinking clearly? Play a game, seriously!
November 16, 2016
Mohan D, Schell J, Angus DC. Not Thinking Clearly? Play a Game, Seriously!. JAMA. 2016;316(18):1867-
1868. doi:10.1001/jama.2016.14174.
https://psnet.ahrq.gov/issue/not-thinking-clearly-play-game-seriously
Heuristics enable experts to build off their …
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www.ahrq.gov/hai/quality/tools/cauti-ltc/engage.html
March 01, 2017 - Engage Residents and Families
Resident and Family Engagement brochure for residents ( PDF , 132 KB)
Describes what resident and family engagement is and how to engage with long-term care facility staff as partners in infection-prevention care.
Resident and Family Engagement: What Is My Role as a Leader? …
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psnet.ahrq.gov/node/73426/psn-pdf
June 23, 2021 - The perfect storm: exam of a medical error and factors
contributing to its possible escalation.
June 23, 2021
Walters GK. The perfect storm: exam of a medical error and factors contributing to its possible escalation. J
Patient Saf. 2021;17(4):e264-e267. doi:10.1097/pts.0000000000000846.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/45869/psn-pdf
March 25, 2017 - Data-driven implementation of alarm reduction
interventions in a cardiovascular surgical ICU.
March 25, 2017
Allan SH, Doyle PA, Sapirstein A, et al. Data-Driven Implementation of Alarm Reduction Interventions in a
Cardiovascular Surgical ICU. Jt Comm J Qual Patient Saf. 2017;43(2):62-70.
doi:10.1016/j.jcjq.2016.1…
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psnet.ahrq.gov/node/47068/psn-pdf
June 25, 2018 - The need for closed-loop systems for management of
abnormal test results.
June 25, 2018
Zuccotti G, Samal L, Maloney FL, et al. The Need for Closed-Loop Systems for Management of Abnormal
Test Results. Ann Intern Med. 2018;168(11):820-821. doi:10.7326/M17-2425.
https://psnet.ahrq.gov/issue/need-closed-loop-systems…
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psnet.ahrq.gov/node/45341/psn-pdf
July 27, 2016 - How to avoid catastrophic events on the ward.
July 27, 2016
Bein B, Seewald S, Gräsner J-T. How to avoid catastrophic events on the ward. Best Pract Res Clin
Anaesthesiol. 2016;30(2):237-45. doi:10.1016/j.bpa.2016.04.003.
https://psnet.ahrq.gov/issue/how-avoid-catastrophic-events-ward
Hospitals require robust esca…
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psnet.ahrq.gov/node/46175/psn-pdf
September 24, 2017 - Applying lessons from social psychology to transform the
culture of error disclosure.
September 24, 2017
Han J, LaMarra D, Vapiwala N. Applying lessons from social psychology to transform the culture of error
disclosure. Med Educ. 2017;51(10):996-1001. doi:10.1111/medu.13345.
https://psnet.ahrq.gov/issue/applying-…
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psnet.ahrq.gov/node/45740/psn-pdf
January 23, 2017 - Patient perspectives on delays in diagnosis and treatment
of cancer: a qualitative analysis of free-text data.
January 23, 2017
Parsonage RK, Hiscock J, Law R-J, et al. Patient perspectives on delays in diagnosis and treatment of
cancer: a qualitative analysis of free-text data. Br J Gen Pract. 2017;67(654):e49-e56…
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psnet.ahrq.gov/node/43079/psn-pdf
May 28, 2014 - Confirming delivery: understanding the role of the
hospitalized patient in medication administration safety.
May 28, 2014
Macdonald M, Heilemann MS, MacKinnon NJ, et al. Confirming delivery: understanding the role of the
hospitalized patient in medication administration safety. Qual Health Res. 2014;24(4):536-50.
…
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psnet.ahrq.gov/node/45455/psn-pdf
June 29, 2017 - JAMA professionalism: disclosure of medical error.
June 29, 2017
Levinson W, Yeung J, Ginsburg S. Disclosure of Medical Error. JAMA. 2016;316(7):764-5.
doi:10.1001/jama.2016.9136.
https://psnet.ahrq.gov/issue/jama-professionalism-disclosure-medical-error
Disclosing medical errors to patients is essential for maint…
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psnet.ahrq.gov/node/45351/psn-pdf
July 20, 2016 - Building a Patient Safety Toolkit for use in general
practice.
July 20, 2016
Bell BG, Spencer R, Marsden K, et al. Building a Patient Safety Toolkit for use in general practice.
InnovAiT. 2016;9(9):557-562. doi:10.1177/1755738016650468.
https://psnet.ahrq.gov/issue/patient-safety-toolkit-general-practice
Although…
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psnet.ahrq.gov/node/47160/psn-pdf
August 08, 2018 - Preventing dispensing errors by alerting for drug
confusions in the pharmacy information system—a
survey of users.
August 8, 2018
Campmans Z, van Rhijn A, Dull RM, et al. Preventing dispensing errors by alerting for drug confusions in
the pharmacy information system-A survey of users. PLoS One. 2018;13(5):e0197469…
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psnet.ahrq.gov/node/60018/psn-pdf
March 04, 2020 - 2019 update on pediatric medical overuse: a systematic
review.
March 4, 2020
Money NM, Schroeder AR, Quinonez RA, et al. 2019 Update on Pediatric Medical Overuse. JAMA Pediatr.
2020;174(4):375-382. doi:10.1001/jamapediatrics.2019.5849.
https://psnet.ahrq.gov/issue/2019-update-pediatric-medical-overuse-systematic-r…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit1-14.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 1.14. Lean Tools and Activities for Clinic Flow
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Cas…
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psnet.ahrq.gov/node/46642/psn-pdf
December 13, 2017 - Intravenous fluid prescribing errors in children: mixed
methods analysis of critical incidents.
December 13, 2017
Conn RL, McVea S, Carrington A, et al. Intravenous fluid prescribing errors in children: Mixed methods
analysis of critical incidents. PLoS One. 2017;12(10):e0186210. doi:10.1371/journal.pone.0186210.
…
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psnet.ahrq.gov/node/47507/psn-pdf
December 21, 2018 - The fate of medicine in the time of AI.
December 21, 2018
Coiera E. The fate of medicine in the time of AI. Lancet. 2018;392(10162):2331-2332. doi:10.1016/S0140-
6736(18)31925-1.
https://psnet.ahrq.gov/issue/fate-medicine-time-ai
Artificial intelligence can improve practice by making synthesized data available in …
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psnet.ahrq.gov/node/45766/psn-pdf
February 08, 2017 - Prescription Drug Monitoring Programs: Evidence-based
Practices to Optimize Prescriber Use.
February 8, 2017
Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, Heller School for Social Policy
and Management at Brandeis University; 2016.
https://psnet.ahrq.gov/issue/prescription-drug-monit…
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psnet.ahrq.gov/node/43528/psn-pdf
October 01, 2014 - Critical incident stress management (CISM) in complex
systems: cultural adaptation and safety impacts in
healthcare.
October 1, 2014
Müller-Leonhardt A, Mitchell SG, Vogt J, et al. Critical Incident Stress Management (CISM) in complex
systems: cultural adaptation and safety impacts in healthcare. Accid Anal Prev. …