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psnet.ahrq.gov/issue/behavioral-mental-health-toolbox
December 14, 2010 - Toolkit
Behavioral & Mental Health Toolbox.
Citation Text:
Behavioral & Mental Health Toolbox. Center for Health Design. Concord, CA: Center for Health Design; 2018.
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psnet.ahrq.gov/issue/health-care-professionals-tools
January 30, 2003 - Multi-use Website
Health Care Professionals Tools.
Citation Text:
Health Care Professionals Tools. Little Rock, AR: National Transitions of Care Coalition; April 2008.
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psnet.ahrq.gov/issue/safely-home-what-happens-when-people-leave-hospital-care-settings
August 02, 2023 - Book/Report
Safely Home: What Happens When People Leave Hospital Care Settings?
Citation Text:
Safely Home: What Happens When People Leave Hospital Care Settings? London, UK: Healthwatch England; July 2015.
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psnet.ahrq.gov/node/33709/psn-pdf
July 01, 2011 - What Have We Learned About Safe Inpatient Handovers?
March 1, 2011
Kripalani S. What Have We Learned About Safe Inpatient Handovers? PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
Perspective
The care of hospitalized patients is marked by numerous tra…
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Annual Perspective
Handoffs and Transitions
Niraj Sehgal, MD, MPH | January 22, 2014
View more articles from the same authors.
Citation Text:
Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
February 26, 2025 - Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes
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March 29, 2023
Innovation
Co…
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
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psnet.ahrq.gov/node/46448/psn-pdf
September 27, 2017 - Simulation in Otolaryngology.
September 27, 2017
Malekzadeh S, ed. Otolaryngol Clin North Am. 2017;50(5):xv-xviii, 875-1036.
https://psnet.ahrq.gov/issue/simulation-otolaryngology
This special issue highlights areas in otolaryngology where simulation is being used to develop
multidisciplinary team-based approaches…
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psnet.ahrq.gov/node/44287/psn-pdf
September 21, 2023 - Patient safety in the operating room.
September 21, 2023
Wahr JA. UpToDate. September 21, 2023.
https://psnet.ahrq.gov/issue/operating-room-hazards-and-approaches-improve-patient-safety
The operating room is a high-risk environment influenced by culture, teamwork, and task complexity. This
review provides an overv…
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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - Spotlight
Spotlight
The Consequences of Miscommunication
Regarding a Possible Artifact
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Kriti Gwal, MD
o AHRQ WebM&M Edit…
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psnet.ahrq.gov/node/45880/psn-pdf
June 29, 2017 - Diagnostic accuracy of GPs when using an early-
intervention decision support system: a high-fidelity
simulation.
June 29, 2017
Kostopoulou O, Porat T, Corrigan D, et al. Diagnostic accuracy of GPs when using an early-intervention
decision support system: a high-fidelity simulation. Br J Gen Pract. 2017;679(656):e…
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psnet.ahrq.gov/node/45858/psn-pdf
March 24, 2017 - From board to bedside: how the application of financial
structures to safety and quality can drive accountability in
a large health care system.
March 24, 2017
Austin M, Demski R, Callender T, et al. From Board to Bedside: How the Application of Financial Structures
to Safety and Quality Can Drive Accountability i…
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psnet.ahrq.gov/node/47152/psn-pdf
October 12, 2018 - A quality initiative: a system-wide reduction in serious
medication events through targeted simulation training.
October 12, 2018
Hebbar KB, Colman N, Williams L, et al. A Quality Initiative: A System-Wide Reduction in Serious
Medication Events Through Targeted Simulation Training. Simul Healthc. 2018;13(5):324-330…
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psnet.ahrq.gov/node/40619/psn-pdf
October 06, 2016 - Sustaining and spreading the reduction of adverse drug
events in a multicenter collaborative.
October 6, 2016
Tham E, Calmes HM, Poppy A, et al. Sustaining and spreading the reduction of adverse drug events in a
multicenter collaborative. Pediatrics. 2011;128(2):e438-45. doi:10.1542/peds.2010-3772.
https://psnet.a…
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psnet.ahrq.gov/node/41481/psn-pdf
September 26, 2012 - Impact of online education on intern behaviour around
Joint Commission national patient safety goals: a
randomised trial.
September 26, 2012
Shaw T, Pernar LI, Peyre S, et al. Impact of online education on intern behaviour around joint commission
national patient safety goals: a randomised trial. BMJ Qual Saf. 201…
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psnet.ahrq.gov/node/46173/psn-pdf
August 20, 2018 - Advances in Patient Safety and Medical Liability.
August 20, 2018
Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality;
2017. AHRQ Publication No. 17-0017-EF.
https://psnet.ahrq.gov/issue/advances-patient-safety-and-medical-liability
This publication describes the re…
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psnet.ahrq.gov/node/40239/psn-pdf
February 23, 2011 - Randomized trial of a warfarin communication protocol
for nursing homes: an SBAR-based approach.
February 23, 2011
Field T, Tjia J, Mazor KM, et al. Randomized trial of a warfarin communication protocol for nursing homes:
an SBAR-based approach. Am J Med. 2011;124(2):179.e1-7. doi:10.1016/j.amjmed.2010.09.017.
htt…
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psnet.ahrq.gov/node/46471/psn-pdf
March 20, 2018 - Diagnostic errors in primary care pediatrics: Project
RedDE.
March 20, 2018
Rinke ML, Singh H, Heo M, et al. Diagnostic Errors in Primary Care Pediatrics: Project RedDE. Acad Peds.
2018;18(2):220-227. doi:10.1016/j.acap.2017.08.005.
https://psnet.ahrq.gov/issue/diagnostic-errors-primary-care-pediatrics-project-red…
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psnet.ahrq.gov/node/37842/psn-pdf
November 20, 2017 - An epistemology of patient safety research: a framework
for study design and interpretation.
November 20, 2017
Brown C, Hofer T, Johal A, et al. An epistemology of patient safety research: a framework for study design
and interpretation. Part 4. One size does not fit all. Quality and Safety in Health Care. 2008;17(…
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psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…