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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-16.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 3.16. Project Team Composition–Cardiology Follow-up Appointment Scheduling
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1…
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/ahcp-sample.html
March 01, 2025 - Re-Engineered Discharge (RED) Toolkit
Tool 3 Continued
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Table of Contents
Re-Engineered Discharge (RED) Toolkit
Tool 1: Overview
Tool 2: How To Begin the Re-engineered Discharge Implementation at Your Hospital
How CMS Measures the "30-Day All Cause Rehospitalization Rate…
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psnet.ahrq.gov/node/44126/psn-pdf
May 13, 2015 - SAFER Electronic Health Records: Safety Assurance
Factors for EHR Resilience.
May 13, 2015
Sittig DF, Singh H, eds. Waretown, NJ: Apple Academic Press; 2015. ISBN: 9781771881173.
https://psnet.ahrq.gov/issue/safer-electronic-health-records-safety-assurance-factors-ehr-resilience
Implementation of electronic health…
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psnet.ahrq.gov/node/34681/psn-pdf
February 09, 2011 - No-fault compensation for medical injuries: the prospect
for error prevention.
February 9, 2011
Studdert DM, Brennan TA. No-Fault Compensation for Medical Injuries. JAMA. 2003;286(2).
doi:10.1001/jama.286.2.217.
https://psnet.ahrq.gov/issue/no-fault-compensation-medical-injuries-prospect-error-prevention
The auth…
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psnet.ahrq.gov/node/74019/psn-pdf
July 11, 2023 - PACT Collaborative: Pathway to Accountability,
Compassion and Transparency.
July 11, 2023
Ariadne Labs, Brigham and Women’s Hospital, Harvard TH Chan School of Public Health.
https://psnet.ahrq.gov/issue/pact-collaborative-pathway-accountability-compassion-and-transparency
Communication and Resolution Programs (CR…
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psnet.ahrq.gov/node/38893/psn-pdf
August 26, 2009 - Patient safety, quality care, and service utilization with
PLATO (Physician Leadership for Accurate and Timely
Orders): a pilot study.
August 26, 2009
Brunt BA, Gifford L. Patient safety, quality care, and service utilization with PLATO (Physician Leadership
for Accurate and Timely Orders): a pilot study. J Nurses…
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psnet.ahrq.gov/node/37966/psn-pdf
January 15, 2009 - Adopting electronic medical records in primary care:
lessons learned from health information systems
implementation experience in seven countries.
January 15, 2009
Ludwick DA, Doucette J. Adopting electronic medical records in primary care: lessons learned from health
information systems implementation experience …
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psnet.ahrq.gov/node/43572/psn-pdf
October 08, 2014 - Awareness of patient safety grows with increased
outpatient surgeries.
October 8, 2014
Aston G. Hosp Health Netw. September 9, 2014.
https://psnet.ahrq.gov/issue/awareness-patient-safety-grows-increased-outpatient-surgeries
As outpatient surgery becomes more prevalent, attention around related safety concerns grow…
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psnet.ahrq.gov/node/44200/psn-pdf
February 18, 2019 - Structured handover in general surgery: an audit of
current practice.
February 18, 2019
Jones HG, Watt B, Lewis L, et al. Structured Handover in General Surgery: An Audit of Current Practice. J
Patient Saf. 2019;15(1):7-10. doi:10.1097/PTS.0000000000000201.
https://psnet.ahrq.gov/issue/structured-handover-general-…
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psnet.ahrq.gov/node/46508/psn-pdf
November 22, 2017 - The checklist: recognize limits, but harness its power.
November 22, 2017
Alspach JAG. The Checklist: Recognize Limits, but Harness Its Power. Crit Care Nurse. 2017;37(5):12-18.
doi:10.4037/ccn2017603.
https://psnet.ahrq.gov/issue/checklist-recognize-limits-harness-its-power
Checklists are used in various health c…
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psnet.ahrq.gov/node/852804/psn-pdf
August 23, 2023 - Five new ways to advance diagnostic safety in your
clinical practice.
August 23, 2023
Bradford A, Goeschel C, Shofer M, et al. Am Fam Physician. 2023;108(1):14-16.
https://psnet.ahrq.gov/issue/five-new-ways-advance-diagnostic-safety-your-clinical-practice
Diagnostic errors are common in the ambulatory environment.…
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psnet.ahrq.gov/node/50674/psn-pdf
November 20, 2019 - The surgical ward round checklist: improving patient
safety and clinical documentation.
November 20, 2019
Krishnamohan N, Maitra I, Shetty VD. The surgical ward round checklist: improving patient safety and
clinical documentation. J Multidiscip Healthc. 2019;12:789-794. doi:10.2147/JMDH.S178896.
https://psnet.ahrq…
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psnet.ahrq.gov/node/854390/psn-pdf
October 11, 2023 - How the physician's financial wellness could impact
patient safety.
October 11, 2023
Richards JL, Brook K. How the physician’s financial wellness could impact patient safety. Postgrad Med J.
2024;100(1182):276-278. doi:10.1093/postmj/qgad076.
https://psnet.ahrq.gov/issue/how-physicians-financial-wellness-could-imp…
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psnet.ahrq.gov/node/866641/psn-pdf
September 04, 2024 - Quality and patient safety improvement is never finished.
September 4, 2024
Kachalia A, Vanhaecht K. Quality and patient safety improvement is never finished. NEJM Catalyst.
2024;5(9). doi:10.1056/cat.24.0316.
https://psnet.ahrq.gov/issue/quality-and-patient-safety-improvement-never-finished
Safety and quality imp…
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psnet.ahrq.gov/node/47700/psn-pdf
January 16, 2019 - Current challenges in health information
technology–related patient safety.
January 16, 2019
Sittig DF, Wright A, Coiera E, et al. Current challenges in health information technology–related patient
safety. Health Inform J. 2020;26(1):181-189. doi:10.1177/1460458218814893.
https://psnet.ahrq.gov/issue/current-chal…
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psnet.ahrq.gov/node/46301/psn-pdf
October 11, 2017 - Care transitions know-how not just for clinicians.
October 11, 2017
Ready T. HealthLeaders Media. September 26, 2017.
https://psnet.ahrq.gov/issue/care-transitions-know-how-not-just-clinicians
Transitions are an error-prone process. This news article reports that organizational leadership should be
engaged in enha…
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psnet.ahrq.gov/node/44629/psn-pdf
December 09, 2015 - Toolkit for Reducing CAUTI in Hospitals.
December 9, 2015
Rockville, MD: Agency for Healthcare Research and Quality; October 2015.
https://psnet.ahrq.gov/issue/toolkit-reducing-cauti-hospitals
Catheter–associated urinary tract infections (CAUTIs) are common complications in hospitalized patients.
This toolkit was …
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digital.ahrq.gov/ahrq-funded-projects/scaling-equipped-clinical-decision-support/citation/consolidated
January 01, 2023 - Use of the consolidated framework for implementation research in a mixed methods evaluation of the EQUIPPED medication safety program in four academic health system emergency departments.
Citation
Kegler MC, Rana S, Vandenberg AE, Hastings SN, Hwang U, Eucker SA, Vaughan CP. Use of the consolidated f…
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digital.ahrq.gov/ahrq-funded-projects/prevent-diabetes-mellitus-predm-clinical-decision-support-intervention/citation/development
January 01, 2023 - Development of a novel clinical decision support tool for diabetes prevention and feasibility of its implementation in primary care.
Citation
O'Brien MJ, Vargas MC, Lopez A, Feliciano Y, Gregory DL, Carcamo P, Mohr L, Mohanty N, Padilla R, Ackermann RT, Persell SD, Feinglass J. Development of a novel …
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digital.ahrq.gov/ahrq-funded-projects/incorporating-patient-reported-outcomes-shared-decision-making-patients/citation/incorporating
January 01, 2023 - Incorporating patient-reported outcomes into shared decision-making in the management of patients with osteoarthritis of the knee: a hybrid effectiveness-implementation study protocol.
Citation
Lin E, Uhler LM, Finley EP, Jayakumar P, Rathouz PJ, Bozic KJ, Tsevat J. Incorporating patient-reported out…