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psnet.ahrq.gov/node/46296/psn-pdf
September 24, 2017 - Perception of safety of surgical practice among operating
room personnel from survey data is associated with all-
cause 30-day postoperative death rate in South Carolina.
September 24, 2017
Molina G, Berry WR, Lipsitz S, et al. Perception of Safety of Surgical Practice Among Operating Room
Personnel From Survey Da…
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www.ahrq.gov/takeheart/training/module-2/index.html
December 01, 2022 - Module 2: Systems Change: Laying the Foundation, Leadership, and Action Plans
YouTube embedded video: https://www.youtube-nocookie.com/embed/IJQC58AGQD0
Video: Systems Change: Laying the Foundation, Leadership, and Action Plans (1:05:01)
Slides: Systems Change: Laying the Foundation, Leadership, and…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/recruitment-letter-nw.pdf
June 01, 2015 - ORPRN Recruitment Letter for Oregon
Oregon Rural
Practice-based
Research Network
Mail code: L222
3181 S.W. Sam Jackson Park Road
Portland, OR 97239-3098
tel 503 494-0361
fax 503 494-1513
www.ohsu.edu/orprn
20 June 2015
Dear Primary Care Colleague,
I am connecting with you regardi…
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www.ahrq.gov/news/newsroom/case-studies/cquips0611.html
October 01, 2014 - County Health Department in Oregon Launches Performance Improvement Activities With AHRQ's Patient Safety Culture Survey
Search All Impact Case Studies
September 2006
The Multnomah County Health Department in Portland, Oregon, initiated a patient safety culture project in 2005 using AHRQ's Hospital Survey o…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety.html
September 01, 2023 - Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error
Next Page
Table of Contents
Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error
Learning From Diagnostic Errors
The Potential of Psychological Safet…
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psnet.ahrq.gov/node/837194/psn-pdf
January 01, 2023 - National improvements in resident physician-reported
patient safety after limiting first-year resident physicians'
extended duration work shifts: a pooled analysis of
prospective cohort studies.
May 25, 2022
Weaver MD, Landrigan CP, Sullivan JP, et al. National improvements in resident physician-reported patient
…
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digital.ahrq.gov/national-webinars/artificial-intelligence-tools-improve-provider-effectiveness-and-patient-outcomes
March 18, 2025 - Artificial Intelligence Tools to Improve Provider Effectiveness and Patient Outcomes
Event Date:
March 18, 2025 | 2:30pm – 4:00pm ET
Event Materials:
Presentation Slides ( PDF , 10.11 MB). Q&A ( PDF , 146 KB)
Your browser does not support inline frames. Please go …
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psnet.ahrq.gov/issue/ihinpsf-lucian-leape-institute
July 12, 2017 - Multi-use Website
IHI Lucian Leape Institute.
Citation Text:
IHI Lucian Leape Institute. Institute for Healthcare Improvement.
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www.ahrq.gov/evidencenow/tools/reduce-disparities.html
February 01, 2025 - Using Data to Reduce Disparities and Improve Quality
Resource: Using Data to Reduce Disparities and Improve Quality: A Guide for Health Care Organizations (PDF, 1 MB; 14 pages) This brief recommends strategies that primary care practices and health care organizations can use to effectively organize and inter…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/action-planning-tool-infographic-sops.pdf
March 01, 2024 - Surveys on Patient Safety Culture Action Planning Steps
ACTION PLANNING FOR
THE SOPS SURVEYS
The AHRQ Surveys on Patient Safety
Culture® (SOPS®) Action Planning Tool
consists of a three-step process to
guide teams as they work to improve
patient safety culture.
1
Identify Areas
To Improve
• What areas do you…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation.html
May 01, 2017 - Implementation
The Implementation Guide takes users step by step through the execution of technical and cultural interventions surrounding the safe surgery checklist. The tools referenced throughout the guide include items such as checklist templates, quality improvement study frameworks, and coaching materials…
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psnet.ahrq.gov/node/44807/psn-pdf
September 29, 2017 - Legal and policy interventions to improve patient safety.
September 29, 2017
Kachalia A, Mello MM, Nallamothu BK, et al. Legal and Policy Interventions to Improve Patient Safety.
Circulation. 2016;133(7):661-71. doi:10.1161/CIRCULATIONAHA.115.015880.
https://psnet.ahrq.gov/issue/legal-and-policy-interventions-impro…
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psnet.ahrq.gov/node/60020/psn-pdf
March 04, 2020 - The eNOTSS platform for surgeons’ nontechnical skills
performance improvement.
March 4, 2020
Pradarelli JC, Yule S, Smink DS. The eNOTSS Platform for Surgeons’ Nontechnical Skills Performance
Improvement. JAMA Surg. 2020;155(5):438-439. doi:10.1001/jamasurg.2019.5880.
https://psnet.ahrq.gov/issue/enotss-platform-s…
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psnet.ahrq.gov/node/44781/psn-pdf
January 13, 2016 - Improving Pediatric Surgery Quality and Outcomes in the
21st Century.
January 13, 2016
Heiss K, ed. Semin Pediatr Surg. 2015;24:265-326.
https://psnet.ahrq.gov/issue/improving-pediatric-surgery-quality-and-outcomes-21st-century
Articles in this special issue introduce quality improvement principles, such as system…
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psnet.ahrq.gov/node/47662/psn-pdf
February 21, 2024 - Lucian Leape Patient Safety Fellowship Award.
February 21, 2024
International Society for Quality in Health Care
https://psnet.ahrq.gov/issue/lucian-leape-patient-safety-fellowship-award
Inspired by the work and leadership of Dr. Lucian Leape, this award is a mentoring program to develop
physicians and leaders see…
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psnet.ahrq.gov/node/50808/psn-pdf
January 15, 2020 - Health Services Research Priorities for Improving
Diagnostic Safety and Quality. Special Emphasis Notice
(SEN).
January 15, 2020
Rockville, MD: Agency for Healthcare Research and Quality. December 27, 2019. Publication No. NOT-
HS-20-004.
https://psnet.ahrq.gov/issue/health-services-research-priorities-improving-…
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psnet.ahrq.gov/node/837695/psn-pdf
July 20, 2022 - Narrowing the mindware gap in medicine.
July 20, 2022
Croskerry P. Narrowing the mindware gap in medicine. Diagnosis (Berl). 2022;9(2):176-183.
doi:10.1515/dx-2020-0128.
https://psnet.ahrq.gov/issue/narrowing-mindware-gap-medicine
In dual process thinking, Type 1 decisions are made rapidly, but can result in diagn…
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psnet.ahrq.gov/node/44640/psn-pdf
February 20, 2016 - The problem with Plan-Do-Study-Act cycles.
February 20, 2016
Reed JE, Card AJ. The problem with Plan-Do-Study-Act cycles. BMJ Qual Saf. 2016;25(3):147-52.
doi:10.1136/bmjqs-2015-005076.
https://psnet.ahrq.gov/issue/problem-plan-do-study-act-cycles
Rapid-cycle improvement methods have been embraced as an approach t…
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psnet.ahrq.gov/node/74858/psn-pdf
February 23, 2022 - Improving responses to safety incidents: we need to talk
about justice.
February 23, 2022
Cribb A, O'Hara JK, Waring J. Improving responses to safety incidents: we need to talk about justice. BMJ
Qual Saf. 2022;31(4):327-330. doi:10.1136/bmjqs-2021-014333.
https://psnet.ahrq.gov/issue/improving-responses-safety-in…
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psnet.ahrq.gov/node/849137/psn-pdf
May 17, 2023 - Medical errors kill thousands of people each year. But are
hospitals getting any safer?
May 17, 2023
Weintraub K. USA Today. May 3, 2023.
https://psnet.ahrq.gov/issue/medical-errors-kill-thousands-people-each-year-are-hospitals-getting-any-safer
The semi-annual Leapfrog Hospital Safety Grades are recognized across…