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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Implementation of Patient Safety Projects
Curated Library
Foundations
Leading change: why transformation efforts fail.
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
Kotter, a professor at Harvard Business School, outlines the eight stages …
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - Annual Perspective
Annual Perspective: Topics in Medication Safety
March 31, 2022
View more articles from the same authors.
Citation Text:
Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer
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July 31, 2023
Innovation
Contact
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - The Impact of Communication on Medication Errors
March 15, 2021
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors
The Case
A 93-year-old man with a history of chronic systolic heart failure…
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/telehealth-covid-19-disposition-comments.pdf
January 03, 2023 - Use of Telehealth During the COVID-19 Era
Comparative Effectiveness Review Disposition of Comments Report
Research Review Title: Use of Telehealth During the COVID-19 Era
Draft report available for public comment from July 15, 2022, to August 12, 2022.
Citation: Hatef E, Wilson RF, Hannum …
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - SPOTLIGHT CASE
A Laceration that Needed a Proper Exam, Not an X-Ray
Citation Text:
Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - Falling Through the Crack (in the Bedrails)
May 1, 2016
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
Case Objectives
Review the epidemiology of patient falls and associated injuries in the hospital set…
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hcup-us.ahrq.gov/reports/race/stand_alone_r_e_rpt.jsp
May 01, 2016 - State Documentation of Racial and Health Disparities to Inform Strategic Action: Summary
An official website of the Department of Health & Human Services
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Careers
…
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hcup-us.ahrq.gov/datainnovations/clinicalcontentenhancementtoolkit/hi24.jsp
July 01, 2016 - Enhancing Hawaii Hospital Information Content: Hospital Engagement.
An official website of the Department of Health & Human Services
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Careers
Contact Us
Esp…
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care
Following Cesarean Delivery.
November 25, 2020
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean
Delivery. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesare…
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digital.ahrq.gov/sites/default/files/docs/publication/BarrierstoMeaningfulUseAppendixD.pdf
October 31, 2013 - Appendix D to the Final Report Barriers to Meaningful Use in Medicaid: Analysis and Recommendations
Form Approved
OMB No. 0935-0186
Exp. Date 10/31/2013
D-1
Appendix D
Barriers to Meaningful Use of Electronic Health
Records in Medicaid
Focus Group Moderator’s Guide
For in-person use with EHR Users
Ma…
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cdsic.ahrq.gov/sites/default/files/2025-09/Final%20508_Measuring%20Patient%20Experience%20of%20PC%20CDS_0.pdf
January 01, 2025 - addition, patient-facing PC CDS care coordination tools, such as cross-provider dashboards or
portals integrating
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digital.ahrq.gov/sites/default/files/Final%20508_Measuring%20Patient%20Experience%20of%20PC%20CDS_0.pdf
December 03, 2024 - addition, patient-facing PC CDS care coordination tools, such as cross-provider dashboards or
portals integrating
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www.ahrq.gov/sites/default/files/2025-02/woods-report.pdf
January 01, 2025 - Final Progress Report: Risk-Informed Clinical Network for Safe Pediatric Emergency Transfers
Risk-Informed Clinical Network for Safe Pediatric
Emergency Transfers
Final Report
October 31, 2012
Principal Investigator: Donna Woods, PhD, EdM
Team Members: Jane Holl, MD, MPH; Abel Kho, MD; Michael Kelleher, MD; Rann…
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digital.ahrq.gov/sites/default/files/docs/citation/EnhancedMedHistoriesImplementationGuide.pdf
November 01, 2011 - Enhanced Medical Histories: A Guide to Implementation in a Health Information Exchange
Enhanced Medication
Histories
Implementation
Handbook
Final ACTION Contract Report
Enhanced Medication Histories
A Guide to Implementation in a Health Information
Exchange
Prepared for:
Agency for Healthca…
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening-october-2018
October 23, 2018 - Share to Facebook
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archived
Final Recommendation Statement
Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening
October 23, 2018
Recommendations made by the U…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/QWUmLEKdwcYA-AKGp5dNaQ
August 09, 2016 - untitled
Copyright 2016 American Medical Association. All rights reserved.
Screening for Lipid Disorders in Children and Adolescents
US Preventive Services Task Force
Recommendation Statement
US Preventive Services Task Force
T he US Preventive Services Task Force (USPSTF) makes rec-
ommendations about the effectiv…
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs024538-adelman-final-report-2022.pdf
January 01, 2022 - Develop and Validate Health IT Safety Measures to Capture Violations of the 5 Rights of Medication Safety – Final Report
Final Progress Report to Agency for Healthcare Research and Quality
Title of Project
Develop and Val…
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digital.ahrq.gov/sites/default/files/docs/publication/r36hs018272-barrette-final-report-2011.pdf
January 01, 2011 - The Impact of Health Information Technology on Demand for Inpatient Services - Final Report
Grant Final Report
Grant ID: R36HS18272
The Impact of Health Information Technology on
Demand for Inpatient Services
Inclusive Dates: 08/31/09 – 04/…