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  1. 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…
  2. 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…
  3. 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…
  4. 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…
  5. 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…
  6. 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, …
  7. 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…
  8. 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…
  9. 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…
  10. 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…
  11. 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…
  12. 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, …
  13. 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…
  14. 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…
  15. 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…
  16. 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…
  17. 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…
  18. 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…
  19. 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…
  20. 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