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psnet.ahrq.gov/node/50406/psn-pdf
October 02, 2019 - The co-design, implementation and evaluation of a
serious board game 'PlayDecide patient safety' to educate
junior doctors about patient safety and the importance of
reporting safety concerns
October 2, 2019
Ward M, Shé ÉN, De Brún A, et al. The co-design, implementation and evaluation of a serious board game
'Pl…
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psnet.ahrq.gov/node/47481/psn-pdf
January 23, 2019 - Implementation of a second victim program in the
neonatal intensive care unit: an interim analysis of
employee satisfaction.
January 23, 2019
Merandi J, Winning AM, Liao NN, et al. Implementation of a second victim program in the neonatal
intensive care unit: An interim analysis of employee satisfaction. J Patient…
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psnet.ahrq.gov/node/36345/psn-pdf
November 15, 2011 - Risk reduction for adverse drug events through
sequential implementation of patient safety initiatives in a
children's hospital.
November 15, 2011
Leonard MS, Cimino M, Shaha S, et al. Risk reduction for adverse drug events through sequential
implementation of patient safety initiatives in a children's hospital. P…
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psnet.ahrq.gov/node/844550/psn-pdf
September 01, 2012 - The effect of a Lean quality improvement implementation
program on surgical pathology specimen accessioning
and gross preparation error frequency.
September 1, 2012
Smith ML, Wilkerson T, Grzybicki DM, et al. The effect of a Lean quality improvement implementation
program on surgical pathology specimen accessionin…
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digital.ahrq.gov/type-care/secondary-care
January 01, 2023 - Secondary Care
Improving Accuracy of Electronic Notes Using a Faster, Simpler Approach
Description
This project developed, implemented, and evaluated a voice-generated enhanced electronic note system and found that it did not improve the time to finalize notes or clinician sat…
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digital.ahrq.gov/sites/default/files/docs/care-transitions-slides-092619.pdf
September 26, 2019 - Yu, Reducing Emergency Room Visits and In-hospitalizations by
Implementing Best Practice for Transitional
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cdsic.ahrq.gov/sites/default/files/2025-03/CDSiC%20Project%20Summary_1.31.25_508c.pdf
January 01, 2025 - AHRQ CDSiC Project Summary March 2025
Making clinical decision support more valuable and meaningful to
patients, clinicians, and healthcare systems
The Clinical Decision Support
Innovation Collaborative
Project Overview and Goals
The Clinical Decision Support Innovation Collaborative (CDSiC) is part of AHRQ’s P…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/finalreportphase2.pdf
September 29, 2014 - to understand the quality improvement activities each
of the participating facilities was already implementing … Coaching Call Attendance
Date Topic Attendance
3/13/2013 Building a team
Understanding and implementing … Implementation process data: Participating facilities report information about progress
in implementing
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs016160-sakuda-final-report-2009.pdf
January 01, 2009 - community health centers (CHCs) and
tertiary centers (TCs) in the state of Hawaii by developing and implementing … Sun Microsystems and the information technology team
(documentation of the planning, developing, implementing … Results
The Holomua Project resulted in:
• Implementing a live health information exchange as
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psnet.ahrq.gov/node/36382/psn-pdf
October 28, 2010 - Design and implementation of an ICU incident registry.
October 28, 2010
van der Veer S, Cornet R, De Jonge E. Design and implementation of an ICU incident registry. Int J Med
Inform. 2007;76(2-3):103-8.
https://psnet.ahrq.gov/issue/design-and-implementation-icu-incident-registry
The authors describe the developmen…
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psnet.ahrq.gov/issue/assessing-residents-communication-skills-disclosure-adverse-event-standardized-patient
December 21, 2016 - Study
Assessing residents' communication skills: disclosure of an adverse event to a standardized patient.
Citation Text:
Posner G, Nakajima A. Assessing residents' communication skills: disclosure of an adverse event to a standardized patient. J Obstet Gynaecol Can. 2011;33(3):262-26…
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psnet.ahrq.gov/issue/surgical-never-events-how-common-are-adverse-occurrences
November 16, 2022 - Commentary
Surgical 'never events': how common are adverse occurrences?
Citation Text:
West JC. Surgical ‘never events’: How common are adverse occurrences? Journal of Healthcare Risk Management. 2009;26(1). doi:10.1002/jhrm.5600260105.
Copy Citation
Format:
DOI Google Sc…
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psnet.ahrq.gov/issue/guidelines-practice-medication-safety
June 26, 2019 - Commentary
Guidelines in practice: medication safety.
Citation Text:
Speth J. Guidelines in practice: medication safety. AORN J. 2023;118(6):380-389. doi:10.1002/aorn.14034.
Copy Citation
Format:
DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/issue/cms-your-mistake-your-problem
November 16, 2022 - Newspaper/Magazine Article
CMS: your mistake, your problem.
Citation Text:
Lubell J. CMS: your mistake, your problem. Eight hospital-acquired conditions won't be paid for. Modern healthcare. 2007;37(33):10-1.
Copy Citation
Format:
Google Scholar PubMed BibTeX EndNote X3 X…
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www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html
July 01, 2023 - Making Health Care Safer II
An Updated Critical Analysis of the Evidence for Patient Safety Practices
This evidence report updates the 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices.
Select for a list of 22 patient safety strategies discussed in the new report that a…
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digital.ahrq.gov/location/usa-ct-new-haven
January 01, 2023 - USA, CT, New Haven
Using Electronic Health Records to Support Decision-Making in Pediatric Obesity Care
Description
This project will evaluate and compare different tools within electronic health records to assist pediatric primary care clinicians with providing higher quality…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d1_pdi_improvementmethodsoverview.pptx
June 02, 2025 - PowerPoint Presentation
Use these PowerPoint slides for any presentations for which they may be useful.
These slides may be useful earlier on in the process than during implementation; feel free to use them at any point in your QI process.
Modify as needed to suit your hospital – you may wish to delete sections of sl…
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psnet.ahrq.gov/issue/apologies-and-medical-error
November 16, 2022 - Commentary
Apologies and medical error.
Citation Text:
Robbennolt JK. Apologies and medical error. Clin Orthop Relat Res. 2009;467(2):376-82. doi:10.1007/s11999-008-0580-1.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/screening-and-diagnosis
January 01, 2010 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
Contact Us
Español
FAQs
Email Updates
The Academy
Integrating Behavioral Health & Primary Care
Expand Navi…
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/implementing-treatment/mitigating-overdose-risk
January 01, 2019 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
Contact Us
Español
FAQs
Email Updates
The Academy
Integrating Behavioral Health & Primary Care
Expand Navi…