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digital.ahrq.gov/sites/default/files/docs/citation/r18hs022701-ornstein-final-report-2014.pdf
January 01, 2014 - Learning from Primary Care Meaningful Use Exemplars - Final Report
Title of Project: Learning from Primary Care Meaningful Use Exemplars
Principal Investigator: Steven M. Ornstein, MD
Team Members: Ruth Jenkins, PhD; Cara Litvin, MD; Lynne N…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/radiation-therapy-brain-metases-protocol.pdf
October 10, 2019 - Research Protocol: Radiation Therapy for Brain Metastases
Evidence-based Practice Center Systematic Review Protocol
Project Title: Radiation Therapy for Brain Metastases: A Systematic Review
I. Background and Objectives for the Systematic Review
The development of secondary malignant growths has particular…
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH
September 28, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.In Conversation With... Freya Spielberg, MD, MPH. PSNet [internet]. Rockville (MD): Agen…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Patterson_48.pdf
May 05, 2008 - In Situ Simulation: Challenges and Results
In Situ Simulation: Challenges and Results
Mary D. Patterson, MD; George T. Blike, MD; Vinay M. Nadkarni, MD
Abstract
In situ simulation, simulation that is physically integrated into the clinical environment, provides
a method to improve reliability and safety in h…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/nonopioid-pharm-chronic-pain-protocol.pdf
February 01, 2019 - Nonopioid Pharmacologic Treatments for Chronic Pain
Evidence-based Practice Center Systematic Review Protocol
Project Title: Nonopioid Pharmacologic Treatments for Chronic Pain
I. Background and Objectives for the Systematic Review
Understanding Chronic Pain
Chronic pain is typically defined as pain l…
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digital.ahrq.gov/sites/default/files/docs/publication/r21hs018766-rimmer-final-report-2012.pdf
January 01, 2012 - Improving Health Care Quality through Health IT for Persons with Intellectual Disabilities: A Final Report and Lessons Learned
Improving Health Care Quality through Health
IT for Persons with Intellectual Disabilities: A
Final Report and Lessons Learned
James H. Rimmer, PhD;
Kueifang (Kelly) Hsieh, …
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP
July 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Raebel_53.pdf
May 07, 2008 - Imbedding Research in Practice to Improve Medication Safety
Imbedding Research in Practice to
Improve Medication Safety
Marsha A. Raebel, PharmD; Elizabeth A. Chester, PharmD; David W. Brand, MSPH;
David J. Magid, MD, MPH
Abstract
Objective: The objective of this project was to improve medication saf…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/key_drivers_descriptions.pdf
February 01, 2019 - EvidenceNow Key Drivers and
Change Strategies
EvidenceNow Key Drivers and
Change Strategies
Tools & Resources
Change Strategy:
Develop a process to search for
new evidence and other changes
related to Key Driver 1
Change Strategy:
Develop an inter-professional QI
team and other changes related to
Key Driver…
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www.ahrq.gov/sites/default/files/2024-07/buckley-report.pdf
January 01, 2024 - Final Progress Report: Midcoast Maine Patient Safety and IT Integration
Title: Midcoast Maine Patient Safety and IT Integration
Principal Investigator: Maureen Buckle y, PhD, RN – Vice President of Patient
Care
Team Members:
Northeast Health and Partner Organizations
Donna Deblois, MS, RN – Executive Dire…
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www.ahrq.gov/sites/default/files/2025-02/silver-report.pdf
January 01, 2025 - Final Progress Report: Process Reliability and Organizational Learning in Home Health Care
PROL IN HOME HEALTH CARE
Title: Process Reliability and Organizational Learning in Home Health Care
Principal Investigator and Team Members:
Michael P. Silver, MPH Principal Investigator
Cher Edmonds Study Coordinator
Robert…
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www.ahrq.gov/sites/default/files/2024-03/small-report.pdf
January 01, 2024 - Final Progress report: Creating High Reliability Organizations
Creating High Reliability Organizations
Principal Investigator:
Stephen D. Small, MD
Key Team Members:
Kay Metis, MS, MA
Bobbie J. Sweitzer, MD
Paul Barach, MD (2001-2002)
Additional funded collaborators:
Julie Mohr, PhD
David Meltzer, MD, …
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www.ahrq.gov/evidencenow/tools/keydrivers/description.html
October 01, 2020 - EvidenceNow Key Drivers and Change Strategies
Below are descriptions of each key driver and change strategy in the EvidenceNOW Key Driver Diagram.
Key Driver 1: Seek, select, and customize the best evidence for use by the practice
The practice of medicine evolves in response to new knowledge about what care…
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psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
April 24, 2024 - Post-Acute Transitional Services: Safety in Home-Based Care Programs
Citation Text:
McElroy V, Ordona RB, Bakerjian D. Post-Acute Transitional Services: Safety in Home-Based Care Programs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
December 31, 2024 - SPOTLIGHT CASE
Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism
Citation Text:
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - SPOTLIGHT CASE
The Risks of a Malpositioned Gastrostomy Tube and Poor Communication
Citation Text:
Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - SPOTLIGHT CASE
Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome
Citation Text:
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Behara.pdf
January 01, 2004 - A Conceptual Framework for Studying the Safety of Transitions in Emergency Care
309
A Conceptual Framework for Studying the
Safety of Transitions in Emergency Care
Ravi Behara, Robert L. Wears, Shawna J. Perry,
Eric Eisenberg, Lexa Murphy, Mary Vanderhoef, Marc Shapiro,
Christopher Beach, Pat Croskerry, Ka…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
February 26, 2008 - Error Producing Conditions in the Intensive Care Unit
Error Producing Conditions in the
Intensive Care Unit
Frank A. Drews, PhD; Adrian Musters, BS; Matthew H. Samore, MD
Abstract
Up to 98,000 patients die because of human error in U.S. hospitals each year. Among the areas
where errors occur frequently is t…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/measuring-blood-pressure-surveillance-160412.pdf
May 29, 2025 - month$
telemonitoring$program$
in$which$BP$
measurements$were$
transmitted$to$a$
pharmacist$case$
manager