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psnet.ahrq.gov/issue/what-do-healthcare-incident-reporting-systems
November 12, 2014 - Review
What to do with healthcare incident reporting systems.
Citation Text:
Pham JC, Girard T, Pronovost PJ. What to do with healthcare Incident Reporting Systems. J Public Health Res. 2013;2(3). doi:10.4081/jphr.2013.e27.
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psnet.ahrq.gov/issue/story-behind-story-physician-skepticism-about-relying-clinical-information-technologies
July 14, 2010 - Study
The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors.
Citation Text:
McAlearney AS, Chisolm DJ, Schweikhart S, et al. The story behind the story: physician skepticism about relying on clinical information tec…
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psnet.ahrq.gov/issue/medical-resident-pharmacist-collaboration-improves-rate-medication-reconciliation
September 24, 2010 - Study
A medical resident–pharmacist collaboration improves the rate of medication reconciliation verification at discharge.
Citation Text:
Caroff DA, Bittermann T, Leonard CE, et al. A Medical Resident-Pharmacist Collaboration Improves the Rate of Medication Reconciliation Verification a…
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psnet.ahrq.gov/issue/technology-governance-and-patient-safety-systems-issues-technology-and-patient-safety
September 14, 2016 - Review
Technology, governance and patient safety: systems issues in technology and patient safety.
Citation Text:
Balka E, Doyle-Waters M, Lecznarowicz D, et al. Technology, governance and patient safety: systems issues in technology and patient safety. Int J Med Inform. 2007;76 Suppl …
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psnet.ahrq.gov/issue/doctors-views-attitudes-towards-peer-medical-error
April 04, 2012 - Study
Doctors' views of attitudes towards peer medical error.
Citation Text:
Asghari F, Fotouhi A, Jafarian A. Doctors' views of attitudes towards peer medical error. Qual Saf Health Care. 2009;18(3):209-12. doi:10.1136/qshc.2007.025015.
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psnet.ahrq.gov/issue/computerization-can-create-safety-hazards-bar-coding-near-miss
March 11, 2011 - Commentary
Classic
Computerization can create safety hazards: a bar-coding near miss.
Citation Text:
McDonald CJ. Computerization can create safety hazards: a bar-coding near miss. Ann Intern Med. 2006;144(7):510-6.
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psnet.ahrq.gov/issue/association-between-culture-climate-and-quality-care-primary-health-care-teams
May 30, 2011 - Commentary
The association between culture, climate and quality of care in primary health care teams.
Citation Text:
Hann M, Bower P, Campbell S, et al. The association between culture, climate and quality of care in primary health care teams. Fam Pract. 2007;24(4):323-9.
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psnet.ahrq.gov/issue/bearing-witness-ethics-practice-storying-physicians-medical-mistake-narratives
July 17, 2024 - Study
Bearing witness to the ethics of practice: storying physicians' medical mistake narratives.
Citation Text:
Carmack HJ. Bearing witness to the ethics of practice: storying physicians' medical mistake narratives. Health Commun. 2010;25(5):449-58. doi:10.1080/10410236.2010.484876.
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psnet.ahrq.gov/issue/surgical-simulation-curriculum-senior-medical-students-based-teamstepps
December 21, 2014 - Study
A surgical simulation curriculum for senior medical students based on TeamSTEPPS.
Citation Text:
Meier AH, Boehler ML, McDowell CM, et al. A surgical simulation curriculum for senior medical students based on TeamSTEPPS. Arch Surg. 2012;147(8):761-6. doi:10.1001/archsurg.2012.1340.…
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psnet.ahrq.gov/issue/wake-hospital-inquiries-impact-staff-and-safety
January 12, 2022 - Commentary
In the wake of hospital inquiries: impact on staff and safety.
Citation Text:
Dunbar JA, Reddy P, Beresford B, et al. In the wake of hospital inquiries: impact on staff and safety. Med J Aust. 2007;186(2):80-3.
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psnet.ahrq.gov/issue/taking-blame-appropriate-responses-medical-error
September 23, 2020 - Commentary
Taking the blame: appropriate responses to medical error.
Citation Text:
Tigard DW. Taking the blame: appropriate responses to medical error. J Med Ethics. 2019;45(2):101-105. doi:10.1136/medethics-2017-104687.
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psnet.ahrq.gov/issue/identification-root-causes-emergency-diagnostic-imaging-delays-three-canadian-hospitals
July 02, 2014 - Study
Identification of root causes for emergency diagnostic imaging delays at three Canadian hospitals.
Citation Text:
Worster A, Fernandes CMB, Malcolmson C, et al. Identification of root causes for emergency diagnostic imaging delays at three Canadian hospitals. J Emerg Nurs. 2006;3…
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psnet.ahrq.gov/issue/lehigh-valley-hospital-engaging-patients-and-families
January 04, 2017 - Award Recipient
Lehigh Valley Hospital: engaging patients and families.
Citation Text:
Anthony R, Ritter M, Davis R, et al. Lehigh Valley Hospital: engaging patients and families. Jt Comm J Qual Patient Saf. 2005;31(10):566-72.
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psnet.ahrq.gov/issue/drs-bramhall-and-bawa-garba-and-rightful-domain-criminal-law
November 13, 2024 - Commentary
Drs Bramhall and Bawa-Garba and the rightful domain of the criminal law.
Citation Text:
Ost S. Drs Bramhall and Bawa-Garba and the rightful domain of the criminal law. J Med Ethics. 2019;45(3):151-155. doi:10.1136/medethics-2018-105135.
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psnet.ahrq.gov/issue/improving-pathologists-communication-skills
May 18, 2022 - Commentary
Improving pathologists' communication skills.
Citation Text:
Dintzis SM. Improving Pathologists' Communication Skills. AMA J Ethics. 2016;18(8):802-8. doi:10.1001/journalofethics.2016.18.8.medu1-1608.
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psnet.ahrq.gov/issue/lost-translation-impact-language-barriers-childrens-healthcare
January 06, 2018 - Review
Lost in translation: impact of language barriers on children's healthcare.
Citation Text:
Goenka PK. Lost in translation: impact of language barriers on children's healthcare. Curr Opin Pediatr. 2016;28(5):659-666. doi:10.1097/MOP.0000000000000404.
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psnet.ahrq.gov/issue/independent-double-checks-high-alert-medications-essential-practice
February 01, 2023 - Commentary
Independent double-checks for high-alert medications: essential practice.
Citation Text:
Baldwin K, Walsh V. Independent double-checks for high-alert medications: essential practice. Nursing (Brux). 2014;44(4):65-7. doi:10.1097/01.NURSE.0000444547.64972.dc.
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www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-measures-atlas/ccrm-atlas-ex58.html
March 01, 2013 - Clinical-Community Relationships Measures (CCRM) Atlas
Exhibit 5-8. Measure 8: Plan of care includes at least one public and/or private community service/resource (Wrap-Around Observation Form-2)
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Table of Contents
Clinical-Community Relationships Measures (CCRM) Atlas
Intro…
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www.ahrq.gov/news/blog/ahrqviews/uspstf-40th-anniversary.html
July 01, 2024 - AHRQ Views: Blog posts from AHRQ leaders
Celebrating the 40th Anniversary of the U.S. Preventive Services Task Force
JUL
8
2024
By
Robert Otto
Valdez,
Ph.D., M.H.S.A.
Robert Otto Valdez, Ph.D., M.H.S.A.
The Ben Franklin proverb, “An ounce of prevention is worth mo…
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www.ahrq.gov/news/newsroom/case-studies/202502.html
February 01, 2025 - Kaiser Permanente School of Anesthesia Uses AHRQ’s Surveys on Patient Safety Culture®, TeamSTEPPS®
Search All Impact Case Studies
February 2025
Kaiser Permanente (KP) School of Anesthesia in Pasadena, California, uses AHRQ’s Surveys on Patient Safety Culture (SOPS®) to improve ambulatory care and expand d…