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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/diagnostic-safety-transitions-care.pdf
June 01, 2023 - Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action
PATIENT
SAFETY
e
Issue Brief 11
Diagnostic Safety Across Transitions of
Care Throughout the Healthcare System:
Current State and a Call to Action
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Issue …
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psnet.ahrq.gov/node/865532/psn-pdf
April 10, 2024 - Let us to the TWISST; Plan, Simulate, Study and Act.
April 10, 2024
Colman N, Hebbar KB. Let us to the TWISST; Plan, Simulate, Study and Act. Pediatr Qual Saf.
2023;8(4):e664. doi:10.1097/pq9.0000000000000664.
https://psnet.ahrq.gov/innovation/let-us-twisst-plan-simulate-study-and-act
In situ simulation can identi…
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hcup-us.ahrq.gov/toolssoftware/surgeryflags_svcproc/SF-SvcProc-ChgLg-v20241-v20251.xlsx
June 01, 2025 - Change log for Surgery Flags Software for Services and Procedures, v2025.1
Table_of_Contents
This Excel file enumerates the changes between the following releases of the Surgery Flags for Services and Procedures
Compared versions: v2024.1 (released July 2024) to v2025.1 (released June 2025)
Table of Contents
Comp…
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www.ahrq.gov/patient-safety/settings/hospital/resetguide.html
July 01, 2020 - Redesigning Systems To Improve Teamwork and Quality for Hospitalized Patients (RESET Project)
A number of challenges impede hospitals’ ability to provide high-quality care to patients on medical services. Teams are large, membership changes over time, and members are often physically scattered, working across m…
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psnet.ahrq.gov/node/40586/psn-pdf
March 21, 2017 - Adopting real-time surveillance dashboards as a
component of an enterprisewide medication safety
strategy.
March 21, 2017
Waitman LR, Phillips IE, McCoy AB, et al. Adopting real-time surveillance dashboards as a component of
an enterprisewide medication safety strategy. Jt Comm J Qual Patient Saf. 2011;37(7):326-3…
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hcup-us.ahrq.gov/reports/factsandfigures/figures/2005/2005_2_10b.jsp
January 01, 2005 - Exhibit 2.10. Injuries
Exhibit 2.10. Injuries
Number of Discharges and Percent Change in Discharges with a Principal Diagnosis of Injuries, 1997-2005
CCS Principal Diagnosis Category and Name
Discharges in Thousands
Standard Errors in Thousands
Percent Change
1997
2005
1997
2005
…
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psnet.ahrq.gov/node/43869/psn-pdf
November 03, 2015 - Clinical safety of England's national programme for IT: a
retrospective analysis of all reported safety events 2005
to 2011.
November 3, 2015
Magrabi F, Baker M, Sinha I, et al. Clinical safety of England's national programme for IT: a retrospective
analysis of all reported safety events 2005 to 2011. Int J Med In…
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www.ahrq.gov/funding/training-grants/grants/active/kawards/kawdsumdelfiol.html
October 01, 2014 - Del Fiol, Guilherme
Summaries of Independent Scientist (K) Awards
Summaries of recently funded projects for Independent Scientist and Mentored Clinical Scientist Development K Awards.
Institution: Duke University
Grant Title: Context-Aware Knowledge Delivery into Electronic Health Records
Grant Number…
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psnet.ahrq.gov/node/43629/psn-pdf
May 01, 2015 - Exposing physicians to reduced residency work hours
did not adversely affect patient outcomes after residency.
May 1, 2015
Jena AB, Schoemaker L, Bhattacharya J. Exposing physicians to reduced residency work hours did not
adversely affect patient outcomes after residency. Health Aff (Millwood). 2014;33(10):1832-40.…
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psnet.ahrq.gov/node/41941/psn-pdf
February 11, 2013 - A cross-sectional study on the relationship between
utilization of root cause analysis and patient safety at 139
Department of Veterans Affairs medical centers.
February 11, 2013
Percarpio KB, Watts V. A cross-sectional study on the relationship between utilization of root cause
analysis and patient safety at 139 …
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psnet.ahrq.gov/node/42039/psn-pdf
December 31, 2014 - Enhancing patient safety and quality of care by improving
the usability of electronic health record systems:
recommendations from AMIA.
December 31, 2014
Middleton B, Bloomrosen M, Dente MA, et al. Enhancing patient safety and quality of care by improving the
usability of electronic health record systems: recommen…
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psnet.ahrq.gov/node/47531/psn-pdf
June 19, 2019 - Patient Safety.
June 19, 2019
Health Aff (Millwood). 2018;37(11):1723-1908.
https://psnet.ahrq.gov/issue/patient-safety-14
The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This
special issue of Health Affairs, published 20 years after that report, highlights achie…
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psnet.ahrq.gov/node/43049/psn-pdf
October 31, 2014 - Vital signs: improving antibiotic use among hospitalized
patients.
October 31, 2014
Fridkin SK, Baggs J, Fagan R, et al. Vital signs: improving antibiotic use among hospitalized patients.
MMWR Morb Mortal Wkly Rep. 2014;63(9):194-200.
https://psnet.ahrq.gov/issue/vital-signs-improving-antibiotic-use-among-hospital…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/hopkinsinternalmed-slides.ppt
January 01, 2013 - Slide 1
Algorithm driving ‘smart’ order set at Hopkins in Medical inpatients
Zeidan AM, et al. Am J Hematol. 2013; 88:545-549
Major Risk Factors
Age > 60
Cancer
Previous VTE
Acute CVA w/ paresis (< 3 mos.)
Thrombophilia
Decompensated NYHA Class III/IV
heart failure
Respiratory failure (ventilator-dependent)
…
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psnet.ahrq.gov/node/39045/psn-pdf
April 04, 2011 - Risks of complications by attending physicians after
performing nighttime procedures.
April 4, 2011
Rothschild JM. Risks of Complications by Attending Physicians After Performing Nighttime Procedures.
JAMA. 2009;302(14):1565-1572. doi:10.1001/jama.2009.1423.
https://psnet.ahrq.gov/issue/risks-complications-attendi…
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psnet.ahrq.gov/node/47610/psn-pdf
March 13, 2019 - Patient safety outcomes under flexible and standard
resident duty-hour rules.
March 13, 2019
Silber JH, Bellini LM, Shea JA, et al; iCOMPARE Research Group. N Engl J Med. 2019;380:905-914.
https://psnet.ahrq.gov/issue/patient-safety-outcomes-under-flexible-and-standard-resident-duty-hour-rules
Duty hour reform for…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state1.html
January 01, 2024 - Current State of Diagnostic Safety: Implications for Research, Practice, and Policy
1. Introduction
Previous Page Next Page
Table of Contents
Current State of Diagnostic Safety: Implications for Research, Practice, and Policy
1. Introduction
2. Methods
3. Results
4. Discussion
References
…
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psnet.ahrq.gov/node/44522/psn-pdf
June 21, 2016 - Impact of an electronic alert notification system
embedded in radiologists' workflow on closed-loop
communication of critical results: a time series analysis.
June 21, 2016
Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in
radiologists' workflow on closed-loop com…
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psnet.ahrq.gov/node/40221/psn-pdf
July 21, 2011 - The association between a prolonged stay in the
emergency department and adverse events in older
patients admitted to hospital: a retrospective cohort
study.
July 21, 2011
Ackroyd-Stolarz S, Guernsey R, Mackinnon NJ, et al. The association between a prolonged stay in the
emergency department and adverse events in…
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psnet.ahrq.gov/node/60248/psn-pdf
April 22, 2020 - Circumstances involved in unsupervised solid dose
medication exposures among young children.
April 22, 2020
Agarwal M, Lovegrove MC, Geller RJ, et al. Circumstances involved in unsupervised solid dose medication
exposures among young children. J Pediatr. 2020;219. doi:10.1016/j.jpeds.2019.12.027.
https://psnet.ahr…