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psnet.ahrq.gov/node/34694/psn-pdf
February 10, 2011 - Computerized surveillance of adverse drug events in
hospital patients.
February 10, 2011
Classen DC, Pestotnik SL, Evans RS, et al. Computerized surveillance of adverse drug events in hospital
patients. JAMA. 1991;266(20):2847-51.
https://psnet.ahrq.gov/issue/computerized-surveillance-adverse-drug-events-hospital-…
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psnet.ahrq.gov/node/47143/psn-pdf
January 30, 2019 - E-learning on risk management. An opportunity for
sharing knowledge and experiences in patient safety.
January 30, 2019
Agra Y, García-Álvarez V, Aibar-Remón C, et al. E-learning on risk management. An opportunity for
sharing knowledge and experiences in patient safety. Int J Health Care Qual. 2019;31(8):639-646.
…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/assessment.html
July 01, 2023 - Labor and Delivery Unit Staff Safety Assessment
AHRQ Safety Program for Perinatal Care
Purpose: To tap into the knowledge and experiences of labor and delivery (L&D) providers and other clinical and nonclinical staff (e.g., health unit coordinators and environmental services personnel) to find ou…
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psnet.ahrq.gov/node/850163/psn-pdf
June 07, 2023 - Managing near-miss reporting in hospitals: the dynamics
between staff members’ willingness to report and
management’s handling of near-miss events.
June 7, 2023
Caspi H, Perlman Y, Westreich S. Managing near-miss reporting in hospitals: the dynamics between staff
members’ willingness to report and management’s han…
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psnet.ahrq.gov/node/50933/psn-pdf
February 26, 2020 - Medication-related harm in older adults following hospital
discharge: development and validation of a prediction
tool.
February 26, 2020
Parekh N, Ali K, Davies JG, et al. Medication-related harm in older adults following hospital discharge:
development and validation of a prediction tool. BMJ Qual Saf. 2020;29(2)…
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psnet.ahrq.gov/node/866344/psn-pdf
January 01, 2025 - Machine learning evaluation of inequities and disparities
associated with nurse sensitive indicator safety events.
July 24, 2024
Georgantes ER, Gunturkun F, McGreevy TJ, et al. Machine learning evaluation of inequities and disparities
associated with nurse sensitive indicator safety events. J Nurs Scholarsh. 2025;5…
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psnet.ahrq.gov/node/46715/psn-pdf
May 02, 2018 - Filling the gap: simulation-based crisis resource
management training for emergency medicine residents.
May 2, 2018
Parsons JR, Crichlow A, Ponnuru S, et al. Filling the gap: simulation-based crisis resource management
training for emergency medicine residents. West J Emerg Med. 2018;19(1):205-210.
doi:10.5811/wes…
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psnet.ahrq.gov/node/44844/psn-pdf
March 02, 2016 - From To Err Is Human to Improving Diagnosis in Health
Care: the risk management perspective.
March 2, 2016
Bunting RF, Groszkruger DP. From To Err Is Human to Improving Diagnosis in Health Care: The risk
management perspective. J Healthc Risk Manag. 2016;35(3):10-23. doi:10.1002/jhrm.21205.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/47042/psn-pdf
June 13, 2018 - Addressing dual patient and staff safety through a team-
based standardized patient simulation for agitation
management in the emergency department.
June 13, 2018
Wong AH, Auerbach MA, Ruppel H, et al. Addressing Dual Patient and Staff Safety Through A Team-
Based Standardized Patient Simulation for Agitation Mana…
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www.ahrq.gov/talkingquality/translate/compare/choose/compare-providers.html
January 01, 2023 - Comparing Health Plan and Provider Quality Scores to Each Other
The simplest and most common strategy is to compare each entity’s performance to the average performance of all the entities you are rating.
Advantages of Comparing to the Community Average
You have all the information you need to make the co…
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www.ahrq.gov/evidencenow/tools/workflow-mapping.html
February 01, 2025 - How to Map Workflows in Health Care Settings
Resource: Mapping and Redesigning Workflow (PDF, 8.8 MB, 69 (Including 54 pages of slides in appendices) pages) Part of an AHRQ curriculum used to train practice facilitators, this resource explains the purpose and process of workflow mapping in a primary care se…
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psnet.ahrq.gov/node/73914/psn-pdf
October 06, 2021 - Is there a mismatch between the perspectives of patients
and regulators on healthcare quality? A survey study.
October 6, 2021
Bouwman R, Bomhoff M, Robben PB, et al. Is there a mismatch between the perspectives of patients and
regulators on healthcare quality? A survey study. J Patient Saf. 2021;17(7):473-482.
do…
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psnet.ahrq.gov/node/72476/psn-pdf
November 18, 2020 - Maintaining perioperative safety in uncertain times:
COVID-19 pandemic response strategies.
November 18, 2020
Mazzola SM, Grous C. Maintaining perioperative safety in uncertain times: COVID-19 pandemic response
strategies. AORN J. 2020;112(4):397-405. doi:10.1002/aorn.13195.
https://psnet.ahrq.gov/issue/maintainin…
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psnet.ahrq.gov/node/46103/psn-pdf
September 23, 2017 - Polypharmacy in the elderly--when good drugs lead to
bad outcomes: a teachable moment.
September 23, 2017
Carroll C, Hassanin A. Polypharmacy in the Elderly-When Good Drugs Lead to Bad Outcomes: A
Teachable Moment. JAMA Intern Med. 2017;177(6):871. doi:10.1001/jamainternmed.2017.0911.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/73466/psn-pdf
July 07, 2021 - COVID-19 and open notes: a new method to enhance
patient safety and trust.
July 7, 2021
Blease CR, Salmi L, Hägglund M, et al. COVID-19 and open notes: a new method to enhance patient
safety and trust. JMIR Ment Health. 2021;8(6):e29314. doi:10.2196/29314.
https://psnet.ahrq.gov/issue/covid-19-and-open-notes-new-m…
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psnet.ahrq.gov/node/866527/psn-pdf
August 14, 2024 - Developing, implementing, evaluating electronic apparent
cause analysis across a health care system.
August 14, 2024
Oster CA, Woods E, Mumma J, et al. Developing, implementing, evaluating electronic apparent cause
analysis across a health care system. Jt Comm J Qual Patient Saf. 2024;50(10):724-736.
doi:10.1016/j…
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psnet.ahrq.gov/node/48019/psn-pdf
June 26, 2019 - Please reconcile, not wait a while.
June 26, 2019
Trivedi A, Sharma S, Ajitsaria R, et al. Please reconcile, not wait a while. Arch Dis Child Educ Pract Ed.
2019;105(2):122-126. doi:10.1136/archdischild-2018-316356.
https://psnet.ahrq.gov/issue/please-reconcile-not-wait-while
Medication reconciliation to ensure ac…
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psnet.ahrq.gov/node/844548/psn-pdf
February 15, 2023 - Use of complete medication history to identify and correct
transitions-of-care medication errors at psychiatric
hospital admission.
February 15, 2023
Vargas V, Blakeslee WW, Banas CA, et al. Use of complete medication history to identify and correct
transitions-of-care medication errors at psychiatric hospital adm…
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psnet.ahrq.gov/node/41646/psn-pdf
September 05, 2012 - Interventions to increase clinical incident reporting in
health care.
September 5, 2012
Parmelli E, Flodgren G, Fraser SG, et al. Interventions to increase clinical incident reporting in health care.
Cochrane Database Syst Rev. 2012;8(8):CD005609. doi:10.1002/14651858.cd005609.pub2.
https://psnet.ahrq.gov/issue/in…
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psnet.ahrq.gov/node/45299/psn-pdf
July 20, 2016 - Reducing readmission at an academic medical center:
results of a pharmacy-facilitated discharge counseling
and medication reconciliation program.
July 20, 2016
Zemaitis CT, Morris G, Cabie M, et al. Reducing Readmission at an Academic Medical Center: Results of a
Pharmacy-Facilitated Discharge Counseling and Medic…