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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Baker_107.pdf
March 30, 2008 - Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems
Analysis of Patient Safety: Converting Complex
Pediatric Chemotherapy Ordering Processes
from Paper to Electronic Systems
Donald K. Baker, PharmD; James M. Hoffman, PharmD; Gregory A. Hal…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/reducing-adverse-drug-1.pdf
March 01, 2020 - Making Healthcare Safer Practices: 9. Reducing Adverse Drug Events in Older Adults
Reducing Adverse Drug Events in Older Adults 9-1
9. Reducing Adverse Drug Events in Older Adults
Authors: Tara R. Earl, Ph.D., M.S.W., Nicole D. Katapodis, M.P.H., and Stephanie R. Schneiderman, M.P.P.
Reviewers: Scott Winiecki, M.D…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/prev-handouts.html
December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Facilitator Training—Handouts: Pressure Ulcer Prevention Implementation
Implementation of the Prevention Reports Into Day-to-Day Practice
Review of the Nursing Home's Pressure Ulcer Prevention Implementation
Scripted Exercise #…
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www.ahrq.gov/sites/default/files/publications/files/ltcmodule1.pdf
June 01, 2012 - Improving Patient Safety in Long-Term Care Facilities, Module 1
Improving
Patient Safety
in Long-Term
Care Facilities
Agency for Healthcare Research and Quality
Advancing Excellence in Health Care www.ahrq.gov
Module 1.
Detecting Change
in a Resident’s
Condition
Student
Workbook
These training materi…
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/references/meta/meta02.html
October 01, 2014 - Studies in Meta-analyses (continued, 2)
This Clinical Practice Guideline used the references below in meta-analyses of research on treating tobacco use and dependence.
Table 6.13. Meta-analysis (2000): Effectiveness of and estimated abstinence rates for various types of format (n = 58 studies)
Barbarin OA. …
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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-Devine_83.pdf
April 06, 2008 - Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences
Implementing an Ambulatory e-Prescribing System:
Strategies Employed and Lessons Learned to
Minimize Unintended Consequences
Emily B. Devine, PharmD, MBA; Jennifer L. Wilson-Norton, RPh, MBA…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/047-evidence-behind-decolonization-strategies-notes.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
The Evidence Behind Decolonization Strategies for MRSA
ICU & Non-ICU
Slide Title and Commentary
Slide Number and Slide
Evidence Behind Decolonization Strategies for MRSA
SAY:
Welcome to this presentation on the current evidence behind decolonization strategies as part of an …
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/after-demonstration.pdf
June 02, 2025 - After The Demonstration: What States Sustained After the End of Federal Grants to Improve Children’s Health Care Quality
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www.ahrq.gov/sites/default/files/publications2/files/distributed-cognition-er-nurses_0.pdf
August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department
Issue Brief 8
Distributed Cognition and the Role
of Nurses in Diagnostic Safety in the
Emergency Department
PATIENT
SAFETY
e
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e
Issue Brief 8
Distributed Cognition and the Rol…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-207-section-2-tables-1-5.pdf
June 02, 2025 - CHIPRA 207: Section 2, Tables 1-5
Section II. Detailed Measure Specifications
Table 1: Exclusion Criteria- ICD-9 Codes for Congenital Anomalies
Congenital Anomaly
Group
ICD-9 Codes
Cardio 746.6, 746.7, 746.81, 746.82, 746.83, 746.84, 746.85, 746.8…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/subglottic-litreview.docx
January 01, 2017 - References
Summary
Continuous or frequent intermittent suctioning of subglottic secretions, via an endotracheal tube (ETT) specially designed with a dorsal lumen to accommodate this, is associated with up to a 50 percent decreased incidence of aspiration and ventilator-associated pneumonia (VAP). Guidelines support …
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/60-tenn-health-coach-sustainability-plan-toolkit.pdf
June 02, 2025 - Health Coach Intervention Sustainability Plan
Health Coach Intervention Sustainability Plan
Medicare Preventative Services
i. In Office Visits, Modifiers and Add-On Codes
a. Annual Wellness Visits
1. Medicare
i. Description-Initial Preventative Physical Exam (IPPE) also known as
“Welcome to Medicare” visit
ii. …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
January 01, 2003 - Do Transient Working Conditions Trigger Medical Errors?
53
Do Transient Working Conditions
Trigger Medical Errors?
Deborah Grayson, Stuart Boxerman, Patricia Potter, Laurie Wolf,
Clay Dunagan, Gary Sorock, Bradley Evanoff
Abstract
Objective: Organizational factors affecting working conditions for health …
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department
Issue Brief 8
Distributed Cognition and the Role
of Nurses in Diagnostic Safety in the
Emergency Department
PATIENT
SAFETY
e
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e
Issue Brief 8
Distributed Cognition and the Rol…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
January 01, 2004 - Creating a Culture of Patient Safety through Innovative Hospital Design
425
Creating a Culture of Patient Safety through
Innovative Hospital Design
John G. Reiling
Abstract
When SynergyHealth, St. Joseph’s Hospital of West Bend, Wisconsin, decided to
relocate and build an 82-bed acute care facility, we reco…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
June 30, 2004 - Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative
133
Mixed Methods Analysis of Medical
Error Event Reports: A Report from
the ASIPS Collaborative
Daniel M. Harris, John M. Westfall, Douglas H. Fernald,
Christine W. Duclos, David R. West, Linda Niebauer,
Linda Ma…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Carayon.pdf
January 01, 2004 - Observing Nurse Interaction with Infusion Pump Technologies
349
Observing Nurse Interaction with
Infusion Pump Technologies
Pascale Carayon, Tosha B. Wetterneck, Ann Schoofs Hundt,
Mustafa Ozkaynak, Prashant Ram, Joshua DeSilvey, Brian Hicks,
Tanita L. Robert, Myra Enloe, Rupa Sheth, Sade Sobande
Abstract…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
February 09, 2005 - From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator
395
From Insight to Implementation:
Lessons from a Multi-site Trial of
a PDA-based Warfarin Dose Calculator
Richard L. Kravitz, Jonathan D. Neufeld, Michael A. Hogarth,
Debora A. Paterniti, William Dager, …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
April 20, 2004 - Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation
437
Barcode Medication Administration:
Lessons Learned from an Intensive
Care Unit Implementation
Mary V. Wideman, Michael E. Whittler, Timothy M. Anderson
Abstract
An electronic barcode medication administration sy…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
March 01, 2004 - Standardizing Medication Error Event Reporting in the U.S. Department of Defense
361
Standardizing Medication Error Event
Reporting in the U.S. Department of Defense
Ronald A. Nosek, Jr., Judy McMeekin, Geoffrey W. Rake
Abstract
Soon after the 1999 Institute of Medicine report, To Err Is Human, was released, …