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psnet.ahrq.gov/node/38507/psn-pdf
February 10, 2015 - From tasks to processes: the case for changing health
information technology to improve health care.
February 10, 2015
Walker JM, Carayon P. From tasks to processes: the case for changing health information technology to
improve health care. Health Aff (Millwood). 2009;28(2):467-477. doi:10.1377/hlthaff.28.2.467.
…
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psnet.ahrq.gov/node/40943/psn-pdf
September 26, 2012 - Getting the message: a quality improvement initiative to
reduce pages sent to the wrong physician.
September 26, 2012
Wong BM, Cheung M, Dharamshi H, et al. Getting the message: a quality improvement initiative to reduce
pages sent to the wrong physician. BMJ Qual Saf. 2012;21(10):855-62.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/38913/psn-pdf
May 24, 2015 - Thinking Outside the Pillbox: A System-wide Approach to
Improving Patient Medication Adherence for Chronic
Disease.
May 24, 2015
Cambridge, MA: New England Healthcare Institute; August 12, 2009.
https://psnet.ahrq.gov/issue/thinking-outside-pillbox-system-wide-approach-improving-patient-medication-
adherence-chro…
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psnet.ahrq.gov/node/36811/psn-pdf
August 26, 2011 - Expanded surgical time out: a key to real-time data
collection and quality improvement.
August 26, 2011
Altpeter T, Luckhardt K, Lewis JN, et al. Expanded surgical time out: a key to real-time data collection and
quality improvement. J Am Coll Surg. 2007;204(4):527-32.
https://psnet.ahrq.gov/issue/expanded-surgica…
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psnet.ahrq.gov/node/37497/psn-pdf
February 15, 2011 - Reporting medical errors to improve patient safety: a
survey of physicians in teaching hospitals.
February 15, 2011
Kaldjian LC, Jones EW, Wu BJ, et al. Reporting medical errors to improve patient safety: a survey of
physicians in teaching hospitals. Arch Intern Med. 2008;168(1):40-6. doi:10.1001/archinternmed.2007…
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psnet.ahrq.gov/node/36331/psn-pdf
October 26, 2010 - Using system analysis to build a safety culture: improving
the reliability of epidural analgesia.
October 26, 2010
Garnerin P, Huchet-Belouard A, Diby M, et al. Using system analysis to build a safety culture: improving
the reliability of epidural analgesia. Acta Anaesthesiol Scand. 2006;50(9):1114-9.
https://psne…
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psnet.ahrq.gov/node/44016/psn-pdf
November 21, 2016 - Partnering to Improve Quality and Safety: A Framework
for Working With Patient and Family Advisors.
November 21, 2016
Chicago, IL: Health Research & Educational Trust; 2015.
https://psnet.ahrq.gov/issue/partnering-improve-quality-and-safety-framework-working-patient-and-family-
advisors
Patient and family advisor…
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psnet.ahrq.gov/node/36785/psn-pdf
March 04, 2011 - Do professional interpreters improve clinical care for
patients with limited English proficiency? A systematic
review of the literature.
March 4, 2011
Karliner LS, Jacobs EA, Chen AH, et al. Do professional interpreters improve clinical care for patients with
limited English proficiency? A systematic review of the…
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psnet.ahrq.gov/node/37594/psn-pdf
September 24, 2010 - Improving sepsis care through systems change: the
impact of a medical emergency team.
September 24, 2010
Sarani B, Brenner SR, Gabel B, et al. Improving sepsis care through systems change: the impact of a
medical emergency team. Jt Comm J Qual Patient Saf. 2008;34(3):179-182, 125.
https://psnet.ahrq.gov/issue/impr…
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psnet.ahrq.gov/node/35391/psn-pdf
April 06, 2011 - Effectiveness of a graduate medical education program
for improving medical event reporting attitude and
behavior.
April 6, 2011
Coyle YM, Mercer SQ, Murphy-Cullen CL, et al. Effectiveness of a graduate medical education program for
improving medical event reporting attitude and behavior. Qual Saf Health Care. 2…
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psnet.ahrq.gov/node/40377/psn-pdf
April 20, 2011 - Lessons learned: use of event reporting by nurses to
improve patient safety and quality.
April 20, 2011
Hession-Laband E, Mantell P. Lessons learned: use of event reporting by nurses to improve patient safety
and quality. J Pediatr Nurs. 2011;26(2):149-55. doi:10.1016/j.pedn.2010.12.005.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/issue/application-system-dynamics-modelling-system-safety-improvement-present-use-and-future
October 27, 2021 - Review
Emerging Classic
The application of system dynamics modelling to system safety improvement: present use and future potential.
Citation Text:
The application of system dynamics modelling to system safety improvement: present use and future potential. Ibrah…
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www.ahrq.gov/news/newsroom/case-studies/cquips1301.html
November 01, 2012 - Newman Memorial Hospital Implements AHRQ's Patient Safety Culture Survey
Search All Impact Case Studies
November 2012
Newman Memorial Hospital, a 79-bed acute hospital in Oklahoma, first implemented AHRQ's "Hospital Survey on Patient Safety Culture" in 2006, when concern about the hospital's patient safety …
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psnet.ahrq.gov/issue/notice-intent-publish-funding-opportunity-announcement-examining-impact-artificial
July 22, 2024 - Grant Announcement
Examining the Impact of Artificial Intelligence (AI) on Healthcare Safety (R18).
Citation Text:
Examining the Impact of Artificial Intelligence (AI) on Healthcare Safety (R18). Rockville, MD: Agency for Research and Quality; July 15, 2024. PA-24-261.
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…
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psnet.ahrq.gov/issue/patient-safety-dialogue-evaluation-intervention-aimed-achieving-improved-patient-safety
December 09, 2020 - Study
Patient Safety Dialogue: evaluation of an intervention aimed at achieving an improved patient safety culture.
Citation Text:
Öhrn A, Rutberg H, Nilsen P. Patient safety dialogue: evaluation of an intervention aimed at achieving an improved patient safety culture. J Patient Saf. …
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psnet.ahrq.gov/issue/eight-recommendations-policies-communicating-abnormal-test-results
March 10, 2011 - Commentary
Eight recommendations for policies for communicating abnormal test results.
Citation Text:
Singh H, Vij MS. Eight recommendations for policies for communicating abnormal test results. Jt Comm J Qual Patient Saf. 2010;36(5):226-232.
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Format:
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psnet.ahrq.gov/issue/resident-led-institutional-patient-safety-and-quality-improvement-process
November 16, 2022 - Study
A resident-led institutional patient safety and quality improvement process.
Citation Text:
Stueven J, Sklar DP, Kaloostian P, et al. A resident-led institutional patient safety and quality improvement process. Am J Med Qual. 2012;27(5):369-76. doi:10.1177/1062860611429387.
Cop…
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psnet.ahrq.gov/issue/what-if-transforming-diagnostic-research-leveraging-diagnostic-process-map-engage-patients
October 27, 2021 - Book/Report
What if?: Transforming Diagnostic Research by Leveraging a Diagnostic Process Map to Engage Patients in Learning from Errors.
Citation Text:
Sheridan S, Merryweather P, Rusz D, et al. What If?: Transforming Diagnostic Research By Leveraging A Diagnostic Process Map To Engage …
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psnet.ahrq.gov/issue/strategies-improving-communication-emergency-department-mediums-and-messages-noisy
November 17, 2010 - Commentary
Strategies for improving communication in the emergency department: mediums and messages in a noisy environment.
Citation Text:
Welch SJ, Cheung DS, Apker J, et al. Strategies for improving communication in the emergency department: mediums and messages in a noisy environ…
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psnet.ahrq.gov/issue/improving-patient-safety-hospitals-contributions-high-reliability-theory-and-normal-accident
October 13, 2010 - Commentary
Improving patient safety in hospitals: contributions of high-reliability theory and normal accident theory.
Citation Text:
Tamuz M, Harrison MI. Improving patient safety in hospitals: Contributions of high-reliability theory and normal accident theory. Health Serv Res. 2006;…