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psnet.ahrq.gov/issue/surfacing-safety-hazards-using-standardized-operating-room-briefings-and-debriefings-large
January 03, 2017 - Study
Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center.
Citation Text:
Bandari J, Schumacher K, Simon M, et al. Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional …
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psnet.ahrq.gov/issue/improving-physicians-hand-over-among-oncology-staff-using-standardized-communication-tool
November 11, 2020 - Commentary
Improving physician's hand over among oncology staff using standardized communication tool.
Citation Text:
Alolayan A, Alkaiyat M, Ali Y, et al. Improving physician's hand over among oncology staff using standardized communication tool. BMJ Qual Improv Rep. 2017;6(1). doi:10.1…
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psnet.ahrq.gov/issue/clinical-handover-trauma-setting-qualitative-study-paramedics-and-trauma-team-members
January 28, 2010 - Study
Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members.
Citation Text:
Evans S, Murray A, Patrick I, et al. Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members. Qual Saf Health Care. 2010;1…
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www.ahrq.gov/sites/default/files/wysiwyg/cpi/about/organization/orgchart/organizationchart-020525.pdf
February 01, 2025 - AHRQ Organization Chart
Office of Extramural Research,
Education and Priority Populations
Francis D. Chesley, Jr., M.D.
Director
Directs the scientific review process for grants and
contracts, manages Agency research training programs,
evaluates the scientific contribution of proposed and
ongoing research an…
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psnet.ahrq.gov/node/43919/psn-pdf
May 01, 2015 - Association of hospital participation in a quality reporting
program with surgical outcomes and expenditures for
Medicare beneficiaries.
May 1, 2015
Osborne NH, Nicholas LH, Ryan AM, et al. Association of hospital participation in a quality reporting
program with surgical outcomes and expenditures for Medicare ben…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/uti-discussion-guide.docx
September 01, 2022 - Urinary Tract Infections – Discussion Guide
Urinary Tract Infections: Discussion Guide
During a regularly scheduled staff meeting, the stewardship leader(s) is encouraged to ask all clinical staff which of the components of the AHRQ Toolkit To Improve Antibiotic Use in Ambulatory Ca…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/sinusitis-discussion-guide.docx
September 01, 2022 - Acute Sinusitis – Discussion Guide
Acute Sinusitis: Discussion Guide
During a regularly scheduled staff meeting, the stewardship leader(s) is encouraged to ask all clinical staff which of the components of the AHRQ Toolkit To Improve Antibiotic Use in Ambulatory Care related to acute sinusitis been revie…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/ape.html
August 01, 2022 - Gap Analysis Facilitator's Guide: Appendix E
Gap Analysis Report Template
The purpose of the Gap Analysis report is to call attention to common themes among the groups, as well as variations among the groups in their perceptions and degree of commitment to CANDOR principles. Findings should be used for target…
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www.ahrq.gov/hai/tools/mvp/how-to-use.html
January 01, 2017 - How To Use This Toolkit
This toolkit consists of four modules to help you improve care for mechanically ventilated patients:
Module on How To Apply CUSP for Mechanically Ventilated Patients
Technical Bundles Module
Ventilator-Associated Events and Outcome Measures Module
Sustainability Module
The …
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www.ahrq.gov/sites/default/files/wysiwyg/sops/sops-action-planning-tool-template.docx
June 02, 2025 - SOPS Action Planning Tool Template
Facility name: Date last updated:
Action Plan for the AHRQ Surveys on Patient Safety Culture
1. Identifying Areas to Improve
1a. What areas do you want to focus on for improvement?
1b. What are your “SMART” goals?
Notes or Comments
Facility name: Date last…
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psnet.ahrq.gov/node/37707/psn-pdf
March 02, 2011 - Bar-coding surgical sponges to improve safety: a
randomized controlled trial.
March 2, 2011
Greenberg CC, Diaz-Flores R, Lipsitz SR, et al. Bar-coding Surgical Sponges To Improve Safety. Ann
Surg. 2009;247(4). doi:10.1097/sla.0b013e3181656cd5.
https://psnet.ahrq.gov/issue/bar-coding-surgical-sponges-improve-safe…
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psnet.ahrq.gov/node/40450/psn-pdf
December 21, 2014 - Unit-based care teams and the frequency and quality of
physician–nurse communications.
December 21, 2014
Gordon M, Melvin P, Graham DA, et al. Unit-based care teams and the frequency and quality of physician-
nurse communications. Arch Pediatr Adolesc Med. 2011;165(5):424-8. doi:10.1001/archpediatrics.2011.54.
htt…
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psnet.ahrq.gov/node/38563/psn-pdf
March 23, 2011 - Market-based control mechanisms for patient safety.
March 23, 2011
Coiera E, Braithwaite J. Market-based control mechanisms for patient safety. Qual Saf Health Care.
2009;18(2):99-103. doi:10.1136/qshc.2007.025833.
https://psnet.ahrq.gov/issue/market-based-control-mechanisms-patient-safety
Efforts to improve patie…
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psnet.ahrq.gov/node/44972/psn-pdf
February 15, 2017 - The effectiveness of electronic differential diagnoses
(DDX) generators: a systematic review and meta-analysis.
February 15, 2017
Riches N, Panagioti M, Alam R, et al. The Effectiveness of Electronic Differential Diagnoses (DDX)
Generators: A Systematic Review and Meta-Analysis. PLoS One. 2016;11(3):e0148991.
doi:…
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psnet.ahrq.gov/node/37514/psn-pdf
February 04, 2015 - Who pays for medical errors? An analysis of adverse
event costs, the medical liability system, and incentives
for patient safety improvement.
February 4, 2015
Mello MM, Studdert DM, Thomas EJ, et al. Who Pays for Medical Errors? An Analysis of Adverse Event
Costs, the Medical Liability System, and Incentives for P…
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psnet.ahrq.gov/node/44750/psn-pdf
January 06, 2016 - Simulation in the executive suite: lessons learned for
building patient safety leadership.
January 6, 2016
Rosen MA, Goeschel CA, Che X-X, et al. Simulation in the Executive Suite: Lessons Learned for Building
Patient Safety Leadership. Simul Healthc. 2015;10(6):372-377.
https://psnet.ahrq.gov/issue/simulation-exe…
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psnet.ahrq.gov/node/39294/psn-pdf
January 03, 2017 - Patient handoffs: standardized and reliable measurement
tools remain elusive.
January 3, 2017
Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt
Comm J Qual Patient Saf. 2010;36(2):52-61.
https://psnet.ahrq.gov/issue/patient-handoffs-standardized-and-reliable-m…
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psnet.ahrq.gov/node/844996/psn-pdf
February 22, 2023 - In situ simulation as a tool to longitudinally identify and
track latent safety threats in a structured quality
improvement initiative for SARS-CoV-2 airway
management: a single-center study.
February 22, 2023
Jafri FN, Yang CJ, Kumar A, et al. In situ simulation as a tool to longitudinally identify and track late…
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psnet.ahrq.gov/node/40271/psn-pdf
May 25, 2011 - Collaborative cohort study of an intervention to reduce
ventilator-associated pneumonia in the intensive care
unit.
May 25, 2011
Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce
ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidem…
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psnet.ahrq.gov/node/60176/psn-pdf
April 01, 2020 - Health and social care-associated harm amongst
vulnerable children in primary care: mixed methods
analysis of national safety reports.
April 1, 2020
Omar A, Rees P, Cooper A, et al. Health and social care-associated harm amongst vulnerable children in
primary care: mixed methods analysis of national safety reports…