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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - SPOTLIGHT CASE
Bad Writing, Wrong Medication
Citation Text:
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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effectivehealthcare.ahrq.gov/sites/default/files/s9.pdf
October 01, 2007 - ORIGINAL ARTICLE
Medicare Part D Data
Major Changes on the Horizon
Leslie M. Greenwald, PhD
Background: The 3 primary administrative data sets developed by
the Centers for Medicare and Medicaid services (CMS) to support
the Medicare Part D program implementation represent a valuable
source of data for health service…
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psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures
Citation Text:
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015437-waters-final-report-2008.pdf
January 01, 2008 - Technology Exchange for Cancer Health Network (Tech-Net)
Grant Final Report
Grant ID: 5UC1HS015437
Technology Exchange for Cancer Health
Network (Tech-Net)
Inclusive Dates: 10/01/04 – 09/30/08
Principal Investigator:
Teresa Waters, PhD
Team Members:
Furhan Yunus, MD
Mindy Me…
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psnet.ahrq.gov/node/852698/psn-pdf
August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to
Increase Safety and Diagnostic Accuracy Innovation
August 30, 2023
https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-
diagnostic-accuracy
Summary
Addressing diagnostic errors to improve outcomes and patient safety h…
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effectivehealthcare.ahrq.gov/sites/default/files/fagerlin-presentation.pdf
October 08, 2025 - Fagerlin-notes-151007 copy-Teresa
When
we talk about patient engagement and
shared
decision-‐making there are a number
of different problems that evolve.
1
First, patients often do not have information they need to make decisions, nor are they involved in
the
decisions as much
as they would
…
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hcup-us.ahrq.gov/reports/statbriefs/sb12.pdf
September 01, 2006 - HCUP Statistical Brief #12: Hospital Stays for Gastrointestinal Diseases, 2004
HEALTHCARE COST AND
UTILIZATION PROJECT
Agen
Res
September 2006
In 200
eases
mately
tions,
all hos
States
condit
Hospit
were s
costly,
nate in
ment t
stay.
Gastro
was th
diseas
accou
GI-rela
Comp
hospit…
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psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - Duplicate Insulin Order
Citation Text:
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
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hcup-us.ahrq.gov/reports/methods/2003_02.jsp
January 01, 2003 - Variables for Revisit Analyses
American Hospital Association (AHA) Linkage Files
AHRQ Quality Indicators
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/delirium-disposition-comments.pdf
September 03, 2019 - The strength of evidence tables (6-24) include a column
titled "Study Limitations" with low & medium indicators
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digital.ahrq.gov/sites/default/files/docs/publication/r21hs018205-kearns-final-report-2012.pdf
January 01, 2012 - Gait changes in older adults: predictors of
falls or indicators of fear.
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www.ahrq.gov/hai/cauti-tools/archived-webinars/connecting-dots-transcript.html
December 01, 2017 - on the X axis, these scores were correlated with a lower composite measure of eight patient safety indicators … The more positive the safety culture, the fewer the patient safety indicators.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/connecting-dots-transcript.doc
October 08, 2013 - on the X axis, these scores were correlated with a lower composite measure of eight patient safety indicators … The more positive the safety culture, the fewer the patient safety indicators.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/antiplatelet-treatment_executive.pdf
September 01, 2013 - 1
Comparative Effectiveness Review
Number 125
Testing of CYP2C19 Variants and Platelet
Reactivity for Guiding Antiplatelet Treatment
Executive Summary
Background
Burden of Disease and Clinical
Setting
Approximately 82 million Americans
currently suffer from some form of
cardiovascular disease.1 In the United …
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psnet.ahrq.gov/issue/variability-measurement-hospital-wide-mortality-rates
July 01, 2016 - Study
Classic
Variability in the measurement of hospital-wide mortality rates.
Citation Text:
Shahian DM, Wolf RE, Iezzoni LI, et al. Variability in the measurement of hospital-wide mortality rates. N Engl J Med. 2010;363(26):2530-9. doi:10.1056/NEJMsa1006396. …
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psnet.ahrq.gov/issue/discrepancies-between-home-medications-listed-hospital-admission-and-reported-medical
November 03, 2021 - Study
Discrepancies between home medications listed at hospital admission and reported medical conditions.
Citation Text:
Slain D, Kincaid SE, Dunsworth TS. Discrepancies between home medications listed at hospital admission and reported medical conditions. Am J Geriatr Pharmacother.…
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psnet.ahrq.gov/issue/how-differences-between-manager-and-clinician-perceptions-safety-culture-impact-hospital
December 21, 2018 - Study
How differences between manager and clinician perceptions of safety culture impact hospital processes of care.
Citation Text:
Richter J, Mazurenko O, Kazley AS, et al. How Differences Between Manager and Clinician Perceptions of Safety Culture Impact Hospital Processes of Care. J P…
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psnet.ahrq.gov/issue/educational-intervention-enhance-nurse-leaders-perceptions-patient-safety-culture
February 14, 2015 - Study
An educational intervention to enhance nurse leaders' perceptions of patient safety culture.
Citation Text:
Ginsburg LR, Norton PG, Casebeer A, et al. An educational intervention to enhance nurse leaders' perceptions of patient safety culture. Health Serv Res. 2005;40(4):997-1020…
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psnet.ahrq.gov/issue/teams-tribes-and-patient-safety-overcoming-barriers-effective-teamwork-healthcare
November 17, 2014 - Review
Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare.
Citation Text:
Weller J, Boyd M, Cumin D. Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare. Postgrad Med J. 2014;90(1061):149-54. doi:10.1136/postgra…
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psnet.ahrq.gov/issue/measurement-harms-community-care-qualitative-study-use-nhs-safety-thermometer
January 23, 2019 - Study
Measurement of harms in community care: a qualitative study of use of the NHS Safety Thermometer.
Citation Text:
Brewster L, Tarrant C, Willars J, et al. Measurement of harms in community care: a qualitative study of use of the NHS Safety Thermometer. BMJ Qual Saf. 2018;27(8):625-6…