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psnet.ahrq.gov/issue/limits-knowledge-management-uk-public-services-modernization-case-patient-safety-and-service
January 29, 2014 - Study
The limits of knowledge management for UK public services modernization: the case of patient safety and service quality.
Citation Text:
Currie G, Waring J, Finn R. THE LIMITS OF KNOWLEDGE MANAGEMENT FOR UK PUBLIC SERVICES MODERNIZATION: THE CASE OF PATIENT SAFETY AND SERVICE QUAL…
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psnet.ahrq.gov/issue/computer-physician-order-entry-benefits-costs-and-issues
May 27, 2011 - Study
Computer physician order entry: benefits, costs, and issues.
Citation Text:
Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med. 2003;139(1):31-9.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-gray-sops-action-planning-tool.pdf
June 02, 2025 - Action Planning for the SOPS Surveys-Introducing SOPS
10
Introducing the SOPS Action
Planning Tool
Laura Gray, MPH
Senior Study Director,
User Network for the AHRQ Surveys on Patient Safety Culture
(SOPS)
Westat
11
AHRQ Surveys on Patient Safety Culture
Surveys of clinicians and staff about the extent to
w…
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psnet.ahrq.gov/issue/risk-factors-iv-compounding-errors-when-using-automated-workflow-management-system
September 23, 2020 - Study
Risk factors for i.v. compounding errors when using an automated workflow management system.
Citation Text:
Deng Y, Lin AC, Hingl J, et al. Risk factors for i.v. compounding errors when using an automated workflow management system. Am J Health Syst Pharm. 2016;73(12):887-893. doi:…
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psnet.ahrq.gov/issue/safety-overlapping-inpatient-orthopaedic-surgery-multicenter-study
April 24, 2018 - Study
Safety of overlapping inpatient orthopaedic surgery: a multicenter study.
Citation Text:
Dy CJ, Osei DA, Maak TG, et al. Safety of Overlapping Inpatient Orthopaedic Surgery: A Multicenter Study. J Bone Joint Surg Am. 2018;100(22):1902-1911. doi:10.2106/JBJS.17.01625.
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psnet.ahrq.gov/issue/review-current-evidence-base-significant-event-analysis
October 14, 2009 - Review
A review of the current evidence base for significant event analysis.
Citation Text:
Bowie P, Pope L, Lough M. A review of the current evidence base for significant event analysis. J Eval Clin Pract. 2008;14(4):520-36. doi:10.1111/j.1365-2753.2007.00908.x.
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Fo…
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psnet.ahrq.gov/issue/healthcare-utilizing-deliberate-discussion-linking-events-huddle-systematic-review
November 16, 2022 - Review
Healthcare Utilizing Deliberate Discussion Linking Events (HUDDLE): a systematic review.
Citation Text:
Glymph DC, Olenick M, Barbera S, et al. Healthcare Utilizing Deliberate Discussion Linking Events (HUDDLE): A Systematic Review. AANA J. 2015;83(3):183-188.
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…
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psnet.ahrq.gov/issue/critical-care-transition-programs-and-risk-readmission-or-death-after-discharge-icu
October 13, 2018 - Review
Critical care transition programs and the risk of readmission or death after discharge from an ICU: a systematic review and meta-analysis.
Citation Text:
Niven DJ, Bastos JF, Stelfox HT. Critical care transition programs and the risk of readmission or death after discharge from …
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psnet.ahrq.gov/issue/systematic-review-malpractice-litigation-diagnosis-and-treatment-acute-stroke
October 19, 2022 - Journal Article
Systematic review of malpractice litigation in the diagnosis and treatment of acute stroke
Citation Text:
Haslett JJ, Genadry L, Zhang X, et al. Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke. Stroke. 2019;50(10):2858-2864. doi:…
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psnet.ahrq.gov/issue/strategies-reduce-diagnostic-errors-systematic-review
February 02, 2022 - Review
Strategies to reduce diagnostic errors: a systematic review
Citation Text:
Abimanyi-Ochom J, Mudiyanselage SB, Catchpool M, et al. Strategies to reduce diagnostic errors: a systematic review. BMC Med Inform Decis Mak. 2019;19(1):174. doi:10.1186/s12911-019-0901-1.
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psnet.ahrq.gov/issue/evaluating-effect-distractions-operating-room-clinical-decision-making-and-patient-safety
November 16, 2022 - Study
Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety.
Citation Text:
Murji A, Luketic L, Sobel ML, et al. Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety. Surg Endosc. 2…
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psnet.ahrq.gov/issue/trends-influencing-cost-care-and-patient-safety
September 25, 2024 - Newspaper/Magazine Article
Trends influencing the cost of care and patient safety.
Citation Text:
Clark R. Trends influencing the cost of care and patient safety. Decision-making in five key areas can improve clinical and economic performance. Health management technology. 2006;27(7):1…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/mowebinar_2014/funaro-0914slides.pdf
January 01, 2014 - Success Stories from the AHRQ Medical Office Survey on Patient Safety Culture
45
45
YUMA DISTRICT HOSPITAL AND
CLINICS
Bev Funaro, RN
Director of Quality and Regulatory Affairs
46
46
Yuma Clinic Background
• Participate in the Hospital and Medical Office
surveys
• Administered survey in 2011 and 2…
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psnet.ahrq.gov/issue/understanding-interdisciplinary-health-care-teams-using-simulation-design-processes-air
November 25, 2009 - Study
Understanding interdisciplinary health care teams: using simulation design processes from the Air Carrier Advanced Qualification Program to identify and train critical teamwork skills.
Citation Text:
Hamman WR, Beaudin-Seiler BM, Beaubien JM. Understanding interdisciplinary healt…
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psnet.ahrq.gov/issue/checklists-change-communication-about-key-elements-patient-care
November 16, 2022 - Study
Checklists change communication about key elements of patient care.
Citation Text:
Newkirk M, Pamplin JC, Kuwamoto R, et al. Checklists change communication about key elements of patient care. J Trauma Acute Care Surg. 2012;73(2 Suppl 1):S75-82. doi:10.1097/TA.0b013e3182606239.
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psnet.ahrq.gov/issue/problems-medical-devices-may-be-severely-under-reported
November 16, 2022 - Study
Problems with medical devices may be severely under-reported.
Citation Text:
Vicente KJ, Kern S. Problems with medical devices may be severely under-reported. Nurs Leadersh (Tor Ont). 2005;18(1):82-8.
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psnet.ahrq.gov/issue/safety-standards-implementing-fall-prevention-interventions-and-sustaining-lower-fall-rates
July 12, 2018 - Commentary
Safety standards: implementing fall prevention interventions and sustaining lower fall rates by promoting the culture of safety on an inpatient rehabilitation unit.
Citation Text:
Leone RM, Adams RJ. Safety Standards: Implementing Fall Prevention Interventions and Sustaining L…
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psnet.ahrq.gov/issue/implementation-and-spread-simple-and-effective-way-improve-accuracy-medicines-reconciliation
March 04, 2009 - Study
Implementation and spread of a simple and effective way to improve the accuracy of medicines reconciliation on discharge: a hospital-based quality improvement project and success story.
Citation Text:
Botros S, Dunn J. Implementation and spread of a simple and effective way to impr…
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digital.ahrq.gov/ahrq-funded-projects/guidelines-decision-support-glides
January 01, 2023 - Guidelines Into Decision Support (GLIDES)
Project Description
Annual Summaries
Publications
Project Details -
Completed
Contract Number
290-08-10011
Funding Mechanism(s)
Clinical Decision Support Services
AHRQ Fu…
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digital.ahrq.gov/health-care-theme/care-coordination
January 01, 2023 - Care Coordination
Scalable Digital Communication Intervention to Support Older Adults and Care Partners Transitioning Home After Major Surgery
Description
This research will develop and evaluate the Perioperative Optimization of Senior Health (myPOSH) mobile application that s…