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psnet.ahrq.gov/node/841799/psn-pdf
August 14, 2023 - The report was updated August 14, 2023, and now includes addendum, errata, and updated author conflict
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psnet.ahrq.gov/node/844775/psn-pdf
September 11, 2019 - The root causes of the opioid epidemic are complex, but inappropriate prescribing of opioids (which
includes
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psnet.ahrq.gov/node/47735/psn-pdf
June 24, 2019 - This report describes the results of two
studies conducted by the Center and includes a retrospective
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psnet.ahrq.gov/node/47026/psn-pdf
January 23, 2019 - The charter includes elements known to contribute to safety, such as a positive work culture
and leadership
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psnet.ahrq.gov/node/44246/psn-pdf
November 15, 2016 - The document
provides strategies for applying efficient and effective RCAs, and it includes tools for
-
psnet.ahrq.gov/node/34802/psn-pdf
January 01, 2016 - Discussion includes background into VA patient safety programs and the role NCPS plays in providing the
-
psnet.ahrq.gov/node/38033/psn-pdf
September 24, 2010 - This description of the process
of implementing medication reconciliation at an urban public hospital includes
-
psnet.ahrq.gov/node/35392/psn-pdf
June 16, 2011 - The paper
usefully includes a detailed table that highlights characteristics and limitations of each
-
psnet.ahrq.gov/node/34698/psn-pdf
January 04, 2017 - The system includes tools to prospectively identify process risks in an organization, analyze the
ways
-
psnet.ahrq.gov/node/40116/psn-pdf
January 05, 2011 - While safety
culture includes domains relating to communication and teamwork between providers, organizational
-
psnet.ahrq.gov/node/35840/psn-pdf
May 27, 2011 - development of the
methodology and the establishment and refinement of the evaluation tool, which includes
-
psnet.ahrq.gov/node/33591/psn-pdf
March 15, 2025 - The GTT includes 53 different triggers, some applicable to all patients and
some inappropriate for certain … The GTT is practical for routine
improvement efforts and not just research studies, and it includes
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psnet.ahrq.gov/issue/sentinel-event
May 30, 2012 - The Sentinel Event Alert Web site includes a complete library of previous sentinel event alerts, along
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psnet.ahrq.gov/issue/measure-dx-resource-identify-analyze-and-learn-diagnostic-safety-events
August 01, 2012 - It includes a checklist to gauge readiness for implementation, measurement strategies , and recommendations
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psnet.ahrq.gov/issue/alliance-innovation-maternal-health
July 26, 2017 - The site, maintained by the American College of Obstetricians and Gynecologists, includes collections
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psnet.ahrq.gov/issue/teamstepps-core-curriculum
August 01, 2012 - The course includes updated evidence reviews, trainer guidance, measurement tools, a pocket guide quick
-
psnet.ahrq.gov/issue/strategies-creating-sustaining-and-improving-culture-safety-health-care-second-edition
May 20, 2015 - The material includes discussions on the role of leadership , professionalism , and high reliability
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psnet.ahrq.gov/issue/toolkit-reducing-cauti-hospitals
June 21, 2016 - The toolkit includes modules that focus on implementation, sustainability , and resources to help hospitals
-
psnet.ahrq.gov/issue/unintended-consequences-new-problems-and-new-solutions
June 27, 2018 - This special issue includes studies, commentaries, and reviews exploring consequences of health IT, including
-
psnet.ahrq.gov/issue/ismp-updates-its-list-drug-name-pairs-tall-man-letters
June 10, 2018 - national survey on how "tall man" lettering has clarified high-consequence drug name confusion and includes