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psnet.ahrq.gov/node/44555/psn-pdf
October 07, 2015 - learning-without-borders-review-implementation-medical-error-reporting-
medecins-sans
An error reporting system was successfully implemented … medication errors and delayed
diagnoses were identified, and additional safety measures and oversight were implemented
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psnet.ahrq.gov/node/47257/psn-pdf
September 26, 2018 - psychiatry-morbidity-and-mortality-incident-reporting-tool-increases-psychiatrist
Incident reporting systems are widely implemented … This institution implemented a psychiatry-specific incident reporting tool.
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psnet.ahrq.gov/issue/bedside-handover-quality-improvement-strategy-transform-care-bedside
October 27, 2010 - This article describes how one hospital implemented bedside handover to improve patient care. … October 13, 2010
Why isn't 'time out' being implemented?
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psnet.ahrq.gov/node/42432/psn-pdf
August 07, 2013 - promote electronic health record (EHR) use,
as of 2012 only 42.2% of hospitals in the United States had implemented … Rural and nonteaching hospitals were less likely to have implemented an EHR compared with larger urban
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psnet.ahrq.gov/issue/shaping-systems-better-behavioral-choices-lessons-learned-fatal-medication-error
February 12, 2020 - the nurse had worked a double shift the day before), failed safety systems (the hospital had recently implemented … A range of safety interventions were implemented as a result.
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psnet.ahrq.gov/issue/two-fatal-cases-accidental-intrathecal-vincristine-administration-learning-death-events
March 24, 2021 - intrathecal vincristine administration, this commentary describes how the health care organization implemented … High-priority drug-drug interaction clinical decision support overrides in a newly implemented
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psnet.ahrq.gov/issue/adverse-effects-medicare-psi-90-hospital-penalty-system-revenue-neutral-hospital-acquired
October 30, 2024 - The Centers for Medicare and Medicaid Services (CMS) first implemented a policy of nonpayment for specific … In 2014, they implemented a value-based purchasing program (the Hospital-Acquired Condition Reduction
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psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
February 26, 2025 - found that AMI 30-day standardized mortality rates decreased between 0.5% and 1.5% after the hospitals implemented … multidisciplinary patient care teams
Additional care navigators
Use By Other Organizations
Prime has implemented … Interest has centered on how Prime implemented the social needs screening tools and how to conduct real-time … Date First Implemented
2018
Problem Addressed
Recent research has … Based on these and other findings, Prime tailored the initiative to local needs and implemented it at
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psnet.ahrq.gov/issue/electronic-prescribing-pediatrics-toward-safer-and-more-effective-medication-management
October 04, 2011 - statement outlines recommendations to ensure that electronic prescribing systems are designed and implemented … Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented
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psnet.ahrq.gov/node/47328/psn-pdf
January 01, 2020 - hospital-penalty-system-revenue-neutral-
hospital-acquired
The Centers for Medicare and Medicaid Services (CMS) first implemented … In 2014, they implemented a value-based purchasing
program (the Hospital-Acquired Condition Reduction
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psnet.ahrq.gov/node/41611/psn-pdf
November 23, 2012 - these alerts was examined in this Dutch
study, which evaluated the degree to which hospital pharmacies implemented … the recommendations 2 years after they were issued, and
only one of those recommendations had been implemented
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psnet.ahrq.gov/node/42836/psn-pdf
January 08, 2014 - comparison-medication-safety-effectiveness-among-nine-critical-access-
hospitals
Approaches to reducing medication errors have not been uniformly implemented … These findings suggest that
increased pharmacy support and bar coding should be implemented in rural
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psnet.ahrq.gov/node/39197/psn-pdf
January 06, 2010 - Since the regulations were implemented, clinical outcomes
have been unaffected, but it remains unclear … recently issued recommendations for new duty hour regulations, and new regulations are expected to be
implemented
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psnet.ahrq.gov/innovation/implementation-medication-reconciliation-risk-stratification-tool-integrated-within
April 12, 2023 - This article describes the experiences of three academic medical centers which implemented risk scoring … Two of the academic medical centers (AMC 1, AMC 2) implemented risk stratification scoring tools developed
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psnet.ahrq.gov/node/33566/psn-pdf
September 15, 2024 - TeamSTEPPS has been successfully implemented
in a variety of clinical settings, including intensive … Teamwork training programs have been implemented in a wide variety of clinical environments, including … facilities participate in the TeamSTEPPS program, and the Medical Team Training
program is being widely implemented
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psnet.ahrq.gov/issue/implementation-pediatric-rapid-response-team-experience-hospital-sick-children-toronto
September 10, 2014 - Rapid response teams (RRTs) have been implemented to improve the identification and management of clinically … This commentary provides insights from a pediatric hospital that implemented an RRT, including its design
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psnet.ahrq.gov/node/36184/psn-pdf
June 13, 2011 - successfully enrolled 88% of acute care hospitals in
the state, but only 50% of hospitals successfully implemented … medication reconciliation, and 65%
implemented communication of critical test results.
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psnet.ahrq.gov/node/37729/psn-pdf
June 12, 2008 - introduction-medical-emergency-teams-australia-and-new-zealand-multi-
centre-study
Medical emergency teams (METs) are a widely implemented … While most hospitals have
implemented an MET, death rates from cardiac arrest appeared to decrease over
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psnet.ahrq.gov/node/865296/psn-pdf
March 27, 2024 - Although successful patient safety interventions have been implemented widely in the United States over … ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
Development
The first set of NPSGs was developed in 2002 and implemented … This check is implemented by utilizing at least
two identifiers such as the patient’s name and date … This safety standard is implemented by marking
the accurate surgical site prior to the procedure and
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psnet.ahrq.gov/node/45344/psn-pdf
January 23, 2017 - accuracy of physical examination findings
in initial progress notes between paper charts and a
newly implemented … accuracy of physical examination findings in initial
progress notes between paper charts and a newly implemented