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psnet.ahrq.gov/issue/shepherding-change-how-market-healthcare-providers-and-public-policy-can-deliver-quality-care
July 20, 2022 - Commentary
Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century.
Citation Text:
Kennedy P, Pronovost P. Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st…
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psnet.ahrq.gov/node/867345/psn-pdf
December 11, 2024 - Implementation of a high-reliability organization
framework in a large integrated health care system: a pre-
post quasi-experimental quality improvement project.
December 11, 2024
Sawyer AM, Thiyarajan S, Essen KE, et al. Implementation of a high-reliability organization framework in a
large integrated health care…
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psnet.ahrq.gov/node/46546/psn-pdf
January 10, 2018 - Using an online quiz-based reinforcement system to
teach healthcare quality and patient safety and care
transitions at the University of California.
January 10, 2018
Shaikh U, Afsar-Manesh N, Amin AN, et al. Using an online quiz-based reinforcement system to teach
healthcare quality and patient safety and care tra…
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psnet.ahrq.gov/node/36843/psn-pdf
January 05, 2017 - Improving medication reconciliation in the outpatient
setting.
January 5, 2017
Varkey P, Cunningham J, Bisping S. Improving medication reconciliation in the outpatient setting. Jt Comm
J Qual Patient Saf. 2007;33(5):286-92.
https://psnet.ahrq.gov/issue/improving-medication-reconciliation-outpatient-setting
The Jo…
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psnet.ahrq.gov/node/72856/psn-pdf
March 17, 2021 - The fusion of incident learning and failure mode and
effects analysis for data-driven patient safety
improvements.
March 17, 2021
Paradis KC, Naheedy KW, Matuszak MM, et al. The fusion of incident learning and failure mode and
effects analysis for data-driven patient safety improvements. Pract Radiat Oncol. 2020;1…
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psnet.ahrq.gov/node/853236/psn-pdf
September 06, 2023 - Video review of simulated pediatric cardiac arrest to
identify errors/latent safety threats: a mixed methods
study.
September 6, 2023
Garcia-Jorda D, Nikitovic D, Gilfoyle E. Video review of simulated pediatric cardiac arrest to identify
errors/latent safety threats: a mixed methods study. Simul Healthc. 2023;18(4…
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psnet.ahrq.gov/node/854376/psn-pdf
October 11, 2023 - Community validation of an approach to detect delayed
diagnosis of appendicitis in big databases.
October 11, 2023
Michelson KA, McGarghan FLE, Waltzman ML, et al. Community validation of an approach to detect
delayed diagnosis of appendicitis in big databases. Hosp Pediatr. 2023;13(7):e170-e174.
doi:10.1542/hpeds…
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psnet.ahrq.gov/node/47932/psn-pdf
August 21, 2019 - Ensuring effective care transition communication:
implementation of an electronic medical record-based
tool for improved cancer treatment handoffs between
clinic and infusion nurses.
August 21, 2019
Pandya C, Clarke T, Scarsella E, et al. Ensuring Effective Care Transition Communication: Implementation
of an Elec…
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psnet.ahrq.gov/node/47216/psn-pdf
July 11, 2018 - Progress Made Towards Improving Opioid Safety, But
Further Efforts to Assess Progress and Reduce Risk Are
Needed.
July 11, 2018
Washington, DC: United States Government Accountability Office; May 2018. Publication GAO-18-380.
https://psnet.ahrq.gov/issue/progress-made-towards-improving-opioid-safety-further-effort…
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psnet.ahrq.gov/node/72551/psn-pdf
December 09, 2020 - Bundle interventions including nontechnical skills for
surgeons can reduce operative time and improve patient
safety.
December 9, 2020
Koike D, Nomura Y, Nagai M, et al. Bundle interventions including nontechnical skills for surgeons can
reduce operative time and improve patient safety. Int J Qual Health Care. 202…
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psnet.ahrq.gov/node/61067/psn-pdf
January 01, 2021 - A program to provide clinicians with feedback on their
diagnostic performance in a learning health system.
October 28, 2020
Meyer AND, Upadhyay DK, Collins CA, et al. A program to provide clinicians with feedback on their
diagnostic performance in a learning health system. Jt Comm J Qual Patient Saf. 2021;47(2):120…
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psnet.ahrq.gov/node/47508/psn-pdf
October 24, 2018 - Root cause analysis of reported patient falls in ORs in the
Veterans Health Administration.
October 24, 2018
Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the
Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.1002/aorn.12372.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/73604/psn-pdf
August 18, 2021 - The effect of providing staff training and enhanced
support to care homes on care processes, safety climate
and avoidable harms: evaluation of a care home quality
improvement programme in England.
August 18, 2021
Damery S, Flanagan S, Jones J, et al. The effect of providing staff training and enhanced support to c…
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psnet.ahrq.gov/node/47980/psn-pdf
May 01, 2019 - Intensive care medicine in 2050: preventing harm.
May 1, 2019
Beet C, Benoit D, Bion J. Intensive care medicine in 2050: preventing harm. Intensive Care Med.
2019;45(4):505-507. doi:10.1007/s00134-018-5353-z.
https://psnet.ahrq.gov/issue/intensive-care-medicine-2050-preventing-harm
This commentary discusses curren…
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psnet.ahrq.gov/node/47554/psn-pdf
November 07, 2018 - Diagnostic Excellence Initiative.
November 7, 2018
Gordon and Betty Moore Foundation.
https://psnet.ahrq.gov/issue/diagnostic-excellence-improving-experience-and-outcomes-patient-care
Missed or delayed diagnoses lead to delays in care and significant preventable harm for patients. Despite
an increasing focus on di…
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psnet.ahrq.gov/node/40806/psn-pdf
October 31, 2011 - How best to measure surgical quality? Comparison of the
Agency for Healthcare Research and Quality Patient
Safety Indicators (AHRQ-PSI) and the American College of
Surgeons National Surgical Quality Improvement Program
(ACS-NSQIP) postoperative adverse events at a single
institution.
October 31, 2011
Cima RR, La…
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psnet.ahrq.gov/node/36294/psn-pdf
July 14, 2010 - Care management implementation and patient safety.
July 14, 2010
Alexander JA; Weiner BJ; Baker LC; et al. J Patient Saf. 2006;2(2):83-96.
https://psnet.ahrq.gov/issue/care-management-implementation-and-patient-safety
The Institute of Medicine's Crossing the Quality Chasm report endorsed care management, defined as…
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psnet.ahrq.gov/node/47054/psn-pdf
July 19, 2018 - A target to achieve zero preventable trauma deaths
through quality improvement.
July 19, 2018
Hashmi ZG, Haut ER, Efron DT, et al. A Target to Achieve Zero Preventable Trauma Deaths Through
Quality Improvement. JAMA Surg. 2018;153(7):686-689. doi:10.1001/jamasurg.2018.0159.
https://psnet.ahrq.gov/issue/target-achi…
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psnet.ahrq.gov/node/73322/psn-pdf
May 26, 2021 - Detecting and assessing suicide ideation during the
COVID-19 pandemic.
May 26, 2021
Simon GE, Stewart CC, Gary MC, et al. Improvement brief: detecting and assessing suicide ideation during
the COVID-19 pandemic. Jt Comm J Qual Patient Saf. 2021;47(7):452-457. doi:10.1016/j.jcjq.2021.04.002.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/46257/psn-pdf
October 11, 2017 - Outcomes of concurrent operations: results from the
American College of Surgeons' National Surgical Quality
Improvement Program.
October 11, 2017
Liu JB, Berian JR, Ban KA, et al. Outcomes of Concurrent Operations: Results From the American College
of Surgeons' National Surgical Quality Improvement Program. Ann Su…