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psnet.ahrq.gov/node/41669/psn-pdf
November 26, 2014 - Patient safety perceptions of primary care providers after
implementation of an electronic medical record system.
November 26, 2014
McGuire MJ, Noronha G, Samal L, et al. Patient safety perceptions of primary care providers after
implementation of an electronic medical record system. J Gen Intern Med. 2013;28(2):18…
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psnet.ahrq.gov/node/41413/psn-pdf
September 26, 2012 - The effects of a 'discharge time-out' on the quality of
hospital discharge summaries.
September 26, 2012
Mohta N, Vaishnava P, Liang C, et al. The effects of a 'discharge time-out' on the quality of hospital
discharge summaries. BMJ Qual Saf. 2012;21(10):885-90.
https://psnet.ahrq.gov/issue/effects-discharge-time-…
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psnet.ahrq.gov/node/46910/psn-pdf
January 23, 2019 - Taking the heat or taking the temperature? A qualitative
study of a large-scale exercise in seeking to measure for
improvement, not blame.
January 23, 2019
Armstrong N, Brewster L, Tarrant C, et al. Taking the heat or taking the temperature? A qualitative study of
a large-scale exercise in seeking to measure for i…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/ginsberg-highlights.pdf
June 02, 2025 - Understanding CAHPS Surveys: A Primer for New Users - Highlights from CAHPS Work
HIGHLIGHTS FROM RECENT
CAHPS WORK
Caren Ginsberg, Ph.D.
Director, CAHPS & SOPS
Center for Quality Improvement & Patient Safety, AHRQ
29
CAHPS V Accomplishments
• Survey and Item Set Development and Revision:
► Incorporating Teleh…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-new-sops-workplace-safety-ginsberg.pdf
June 02, 2025 - New AHRQ SOPS® Workplace Safety Supplemental Items for Hospitals - Ginsberg
AHRQ’s Surveys on Patient Safety Culture™
(SOPS®) Program
Caren Ginsberg, Ph.D.
Center for Quality Improvement and Patient Safety, AHRQ
6
AHRQ’s SOPS Program
• Initiated and funded by AHRQ since 2001 to advance the understanding,
measu…
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psnet.ahrq.gov/node/47727/psn-pdf
January 23, 2019 - Improving resident and fellow engagement in patient
safety through a graduate medical education incentive
program.
January 23, 2019
Turner DA, Bae J, Cheely G, et al. Improving Resident and Fellow Engagement in Patient Safety Through
a Graduate Medical Education Incentive Program. J Gen Intern Care. 2018;10(6):671…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-19.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 4.19. Major Factors that Inhibit Lean Success
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Case …
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psnet.ahrq.gov/node/36013/psn-pdf
September 22, 2010 - A new safety event reporting system improves physician
reporting in the surgical intensive care unit.
September 22, 2010
Schuerer DJE, Nast PA, Harris CB, et al. A new safety event reporting system improves physician reporting
in the surgical intensive care unit. J Am Coll Surg. 2006;202(6):881-887.
https://psnet.…
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digital.ahrq.gov/2018-year-review
January 01, 2018 - 2018 Year in Review
About the Report
This Year in Review report summarizes the research activities and outcomes funded by the AHRQ Health IT Program in 2018. The objective of this report is to support AHRQ stakeholders, including patients, clinicians, researchers, and policymakers, to:…
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digital.ahrq.gov/program-overview/research-stories/engaging-empowering-patients-caregivers
January 01, 2023 - Engaging and Empowering Patients and Caregivers
2023 Research Stories
Advancing Patient-Centered Clinical Decision Support Working closely with patients to design and implement clinical decision support is important. The uptake of evidence into clinical practice depends o…
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www.ahrq.gov/hai/tools/ambulatory-surgery/index.html
March 01, 2023 - Toolkit To Improve Safety in Ambulatory Surgery Centers
The Toolkit To Improve Safety in Ambulatory Surgery Centers helps ambulatory surgery centers (ASCs) make care safer for their patients. ASCs can use the toolkit to apply the proven principles and methods of AHRQ's Comprehensive Unit-based Safety Program (C…
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www.ahrq.gov/ncepcr/research/index.html
January 01, 2024 - Research Initiatives
For more than a decade, AHRQ has made major investments in research initiatives to better understand the challenges primary care practices face as they work to provide higher quality care and better health outcomes. Even during the fraught environment of the COVID pandemic, these investme…
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psnet.ahrq.gov/node/44834/psn-pdf
January 27, 2016 - Sustaining reliability on accountability measures at the
Johns Hopkins Hospital.
January 27, 2016
Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the
Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531-544.
https://psnet.ahrq.gov/issue/sustain…
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psnet.ahrq.gov/node/45083/psn-pdf
July 18, 2016 - Toward a safer health care system: the critical need to
improve measurement.
July 18, 2016
Jha AK, Pronovost P. Toward a Safer Health Care System: The Critical Need to Improve Measurement.
JAMA. 2016;315(17):1831-2. doi:10.1001/jama.2016.3448.
https://psnet.ahrq.gov/issue/toward-safer-health-care-system-critical-n…
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www.ahrq.gov/pqmp/grantees/coe-2-0.html
September 01, 2021 - PQMP 2.0 Centers of Excellence
In October 2016, the Pediatric Quality Measures Program (PQMP) embarked on a new phase of work seeking to improve and refine quality measures that were developed across diverse areas during the initial phase of the PQMP.
In accordance with Title III, Sec. 304(b) of the Medicare…
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psnet.ahrq.gov/node/39336/psn-pdf
March 21, 2017 - Does teamwork improve performance in the operating
room? A multilevel evaluation.
March 21, 2017
Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating
room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133-42.
https://psnet.ahrq.gov/issue/does-teamwork-im…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-1.html
September 01, 2023 - Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error
Learning From Diagnostic Errors
Previous Page Next Page
Table of Contents
Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error
Learning From Diagnost…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology3.html
April 01, 2025 - Exploration of Foundational Terminology and Paradigms for Improving Diagnosis
Definitions of Diagnosis
Previous Page Next Page
Table of Contents
Exploration of Foundational Terminology and Paradigms for Improving Diagnosis
Introduction
Perspectives on Diagnostic Improvement
Definitions of Diag…
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www.ahrq.gov/research/findings/final-reports/ptflow/index.html
July 01, 2018 - Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals
Next Page
Table of Contents
Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals
Acknowledgments
Executive Summary
Section 1. The Need to Address Emergency Department Crow…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/03-diagnostic-safety-infographic.pdf
August 01, 2021 - Did You Know, Safety Infographic
Did you know...
57%
of all diagnostic
failures happen in
ambulatory care.1
1 in 20
patients who attend a
primary care appointment
this year will experience a
diagnostic error.2
79% of diagnostic
errors are related to the
patient-clinician encounter.3
up to
56%
of these …