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psnet.ahrq.gov/issue/unintended-harm-associated-hospital-readmissions-reduction-program
August 20, 2018 - Commentary
Unintended harm associated with the Hospital Readmissions Reduction Program.
Citation Text:
Fonarow GC. Unintended Harm Associated With the Hospital Readmissions Reduction Program. JAMA. 2018;320(24):2539-2541. doi:10.1001/jama.2018.19325.
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psnet.ahrq.gov/issue/shifting-learning-curve
March 09, 2009 - Commentary
Shifting the learning curve.
Citation Text:
Reynolds T, Kong M-L. Shifting the learning curve. BMJ. 2010;341:c6260. doi:10.1136/bmj.c6260.
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psnet.ahrq.gov/issue/not-thinking-clearly-play-game-seriously
January 17, 2018 - Commentary
Not thinking clearly? Play a game, seriously!
Citation Text:
Mohan D, Schell J, Angus DC. Not Thinking Clearly? Play a Game, Seriously!. JAMA. 2016;316(18):1867-1868. doi:10.1001/jama.2016.14174.
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DOI Google Scholar PubMed BibTeX EndNote X3 X…
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psnet.ahrq.gov/issue/are-health-professionals-perceptions-patient-safety-related-figures-safety-incidents
November 23, 2011 - Study
Are health professionals' perceptions of patient safety related to figures on safety incidents?
Citation Text:
Martijn L, Harmsen M, Gaal S, et al. Are health professionals' perceptions of patient safety related to figures on safety incidents? J Eval Clin Pract. 2013;19(5):944-7.…
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psnet.ahrq.gov/issue/reducing-methicillin-resistant-staphylococcus-aureus-mrsa-infections
January 03, 2018 - Commentary
Reducing methicillin-resistant Staphylococcus aureus (MRSA) infections.
Citation Text:
Griffin F. 5 Million Lives Campaign. Reducing methicillin-resistant Staphylococcus aureus (MRSA) infections. Jt Comm J Qual Patient Saf. 2007;33(12):726-31.
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psnet.ahrq.gov/issue/misdiagnosis-analysis-based-case-record-review-proposals-aimed-improve-diagnostic-processes
November 12, 2014 - Study
Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes.
Citation Text:
Neale G, Hogan H, Sevdalis N. Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes. Clin Med (Lond). 2011;11(…
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psnet.ahrq.gov/issue/standardized-patient-identification-and-specimen-labeling-retrospective-analysis-improving
October 19, 2022 - Study
Standardized patient identification and specimen labeling: a retrospective analysis on improving patient safety.
Citation Text:
Kim JK, Dotson B, Thomas S, et al. Standardized patient identification and specimen labeling: a retrospective analysis on improving patient safety. J Am…
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psnet.ahrq.gov/issue/bullying-hidden-threat-patient-safety
August 22, 2012 - Commentary
Bullying: a hidden threat to patient safety.
Citation Text:
Longo J, Hain D. Bullying: a hidden threat to patient safety. Nephrol Nurs J. 2014;41(2):193-99; quiz 200.
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psnet.ahrq.gov/issue/use-complex-adaptive-systems-metaphor-achieve-professional-and-organizational-change
November 11, 2020 - Commentary
Use of complex adaptive systems metaphor to achieve professional and organizational change.
Citation Text:
Rowe A, Hogarth A. Use of complex adaptive systems metaphor to achieve professional and organizational change. J Adv Nurs. 2005;51(4). doi:10.1111/j.1365-2648.2005.0351…
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psnet.ahrq.gov/issue/redesigning-morbidity-and-mortality-program-university-affiliated-pediatric-anesthesia
March 27, 2024 - Commentary
Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department.
Citation Text:
McDonnell C, Laxer RM, Roy L. Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department. Jt Comm J Qual Pat…
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psnet.ahrq.gov/issue/using-multidisciplinary-rounds-improve-patient-safety-through-venous-thromboembolism
April 20, 2016 - Study
Using multidisciplinary rounds to improve patient safety through venous thromboembolism prevention awareness.
Citation Text:
Karasin B, Maund C. Using Multidisciplinary Rounds to Improve Patient Safety Through Venous Thromboembolism Prevention Awareness. Jt Comm J Qual Patient Saf.…
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psnet.ahrq.gov/issue/safe-handling-concentrated-electrolyte-products-outsourcing-facilities-during-critical-drug
December 15, 2021 - Press Release/Announcement
Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages.
Citation Text:
Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages. National Alert Network. …
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psnet.ahrq.gov/issue/checklist-tool-error-management-and-performance-improvement
June 29, 2011 - Review
The checklist--a tool for error management and performance improvement.
Citation Text:
Hales BM, Pronovost P. The checklist--a tool for error management and performance improvement. J Crit Care. 2006;21(3):231-5.
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psnet.ahrq.gov/issue/using-medication-error-prioritization-system-improve-patient-safety
May 01, 2020 - Commentary
Using the medication error prioritization system to improve patient safety.
Citation Text:
Polnariev A. Using the Medication Error Prioritization System To Improve Patient Safety. P T. 2016;41(1):54-9.
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psnet.ahrq.gov/issue/right-and-wrong-way-talk-patients-about-adverse-events
November 01, 2023 - Newspaper/Magazine Article
The right and wrong way to talk to patients about adverse events.
Citation Text:
Beaulieu-Volk D. The right and wrong way to talk to patients about adverse events. Medical economics. 2014;91(11):52-5.
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www.ahrq.gov/news/blog/ahrqviews/burnout-in-primary-care-guide.html
April 01, 2023 - AHRQ Views: Blog posts from AHRQ leaders
New Guide Offers Strategies To Reduce Clinician Burdens
APR
24
2023
By
Robert Otto
Valdez,
Ph.D., M.H.S.A.
Robert Otto Valdez, Ph.D., M.H.S.A.
In recent years, primary care physicians have struggled with burnout brought on …
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psnet.ahrq.gov/issue/age-related-covid-19-vaccine-mix-ups
June 13, 2018 - Press Release/Announcement
Age-related COVID-19 vaccine mix-ups.
Citation Text:
Age-related COVID-19 vaccine mix-ups. National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. December 6, 2021.
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digital.ahrq.gov/care-setting/hospital-outpatient
January 01, 2023 - Outpatient
Examining the Feasibility and Effectiveness of an mHealth Solution Designed to Enhance Clinical Outcomes Among Patients Attending Physical Therapy for Musculoskeletal Pain
Description
This research examines whether remote therapeutic monitoring can improve physical …
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www.ahrq.gov/news/newsroom/case-studies/202502.html
June 01, 2025 - Kaiser Permanente School of Anesthesia Uses AHRQ’s Surveys on Patient Safety Culture®, TeamSTEPPS®
Search All Impact Case Studies
June 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 docto…
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psnet.ahrq.gov/issue/surveys-patient-safety-culture-sops-medical-office-survey-2022-user-database-report
June 01, 2022 - Book/Report
Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2022 User Database Report.
Citation Text:
Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2022 User Database Report. Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare R…