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psnet.ahrq.gov/issue/medical-errors-leave-devastating-impact-families-professionals
August 11, 2010 - Newspaper/Magazine Article
Medical errors leave devastating impact on families, professionals.
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Medical errors leave devastating impact on families, professionals. Bernhard B.
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psnet.ahrq.gov/issue/leadership-response-sentinel-event-respectful-effective-crisis-management
July 12, 2017 - Multi-use Website
Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management.
Citation Text:
Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management. Institute for Healthcare Improvement.
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psnet.ahrq.gov/issue/what-new-doctor-learned-about-medical-mistakes-her-moms-death
March 03, 2021 - Newspaper/Magazine Article
What a new doctor learned about medical mistakes from her Mom's death.
Citation Text:
What a new doctor learned about medical mistakes from her Mom's death. Allen M. ProPublica. January 9, 2013.
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psnet.ahrq.gov/issue/hospitals-learn-say-sorry
October 24, 2012 - Newspaper/Magazine Article
Hospitals learn to say sorry.
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Hospitals learn to say sorry. Lerner M.
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digital.ahrq.gov/2019-year-review/research-summary/emerging-innovative-newly-funded-research/using-direct-patient-technology-and-clinical-decision-support
January 01, 2019 - Using Direct-to-Patient Technology and Clinical Decision Support to Increase Type 2 Diabetes Screening
A low-cost, novel direct-to-patient CDS tool that identifies patients at high risk of type 2 diabetes and offers them a screening test could increase the number of patients screened and save physicians’ time.
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www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/current-processes-refining-evidence-based-recommendation-development-table-1
June 01, 2007 - Current Processes: Refining Evidence-based Recommendation Development - Table 1
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Table 1. Procedures for Developing a Recommendation Statement a
Activity b
Responsib…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/checklist
January 01, 2023 - Checklist
Also Known As
Check Sheet
Examples
Nelson E, Batalden P, Godfrey M. Appendix A: primary care workbook. Quality by design: a clinical microsystems approach. San Francisco: Jossey-Bass; 2007. p. 385-431.
EHR Go-Live Planning Checklist ( PDF , 541KB)
EHR Implementation Checkli…
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psnet.ahrq.gov/issue/patient-safety-18
June 26, 2013 - Special or Theme Issue
Patient Safety.
Citation Text:
Patient Safety. Halamek LP, ed. Semin Perinatol. 2019;43(8):151172-151182.
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/3yeJ6L7nXxuVtnaU75gecT
January 01, 2011 - Screening for Hepatitis C Virus Infection in Adults: Clinical Summary of U.S. Preventive Services Task Force Recommendation
SCREENING FOR HEPATITIS C VIRUS INFECTION IN ADULTS
CLINICAL SUMMARY OF U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATION
Population Persons at high risk for infection and adults born …
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psnet.ahrq.gov/issue/socio-cultural-perspective-patient-safety
August 06, 2016 - Book/Report
A Socio-cultural Perspective on Patient Safety.
Citation Text:
A Socio-cultural Perspective on Patient Safety. Rowley E, Waring J, eds. Farnham Surrey, UK: Ashgate Publishing Limited; 2011. ISBN: 9781409408628.
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psnet.ahrq.gov/issue/2014-annual-benchmarking-report-malpractice-risks-diagnostic-process
September 26, 2012 - Book/Report
2014 Annual Benchmarking Report: Malpractice Risks in the Diagnostic Process.
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2014 Annual Benchmarking Report: Malpractice Risks in the Diagnostic Process. Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014.
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psnet.ahrq.gov/issue/collaborative-accountability-and-improvement
August 14, 2018 - Multi-use Website
Collaborative for Accountability and Improvement.
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Collaborative for Accountability and Improvement. University of Washington.
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/problem
January 01, 2023 - Problem Solving
Use Case
Description
A use case is a set of instructions that an individual in a process completes to go through one single step in that process. It describes what the user does to interact with a system.
5W2H
Description
5W2H is…
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psnet.ahrq.gov/issue/contributions-ergonomics-and-human-factors
January 28, 2015 - Special or Theme Issue
Contributions from Ergonomics and Human Factors.
Citation Text:
Contributions from Ergonomics and Human Factors. Qual Saf Health Care. 2010;19(suppl 3):i1-i79.
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psnet.ahrq.gov/issue/survey-results-reveal-tubing-misconnections-are-common-and-underreported-parts-i-and-ii
December 18, 2024 - Newspaper/Magazine Article
Survey results reveal tubing misconnections are common and underreported—Parts I and II.
Citation Text:
Survey results reveal tubing misconnections are common and underreported—Parts I and II. ISMP Medication Safety Alert! Acute Care. October 31, 2024;29(22 & 2…
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psnet.ahrq.gov/issue/when-surgeon-should-just-say-im-sorry
February 05, 2014 - Newspaper/Magazine Article
When a surgeon should just say 'I'm sorry'.
Citation Text:
When a surgeon should just say 'I'm sorry'. Cohen E. CNN. March 24, 2016.
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psnet.ahrq.gov/issue/fires-during-surgeries-bigger-risk-thought
August 24, 2016 - Newspaper/Magazine Article
Fires during surgeries a bigger risk than thought.
Citation Text:
Fires during surgeries a bigger risk than thought. Kowalczyk L. Boston Globe. November 7, 2007
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/cause-and-effect-diagram
January 01, 2023 - Cause-and-Effect Diagram
Also Known As
Ishikawa Diagram
Fishbone Diagram
Examples
Roberts L, Johnson C, Shanmugam R, et al. Computer simulation and six-sigma tools applied to process improvement in an emergency department. 17th Annual Society for Health Systems Management Engineering F…
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digital.ahrq.gov/sites/default/files/docs/page/THQITStoriesCrandall2010.pdf
December 01, 2009 - Network of Rural Hospitals in Iowa Redesign Patient Care Workflow to Use Electronic Health Records
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digital.ahrq.gov/organization/university-illinois-chicago
January 01, 2023 - University of Illinois at Chicago
Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error and Improve Outcomes in Ambulatory Care
Description
This research studied whether clinical decision support could reduce contextual errors, improve patien…