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psnet.ahrq.gov/issue/open-disclosure-among-general-practitioners-second-victim-patient-safety-incident-cross
February 15, 2023 - Study
Open disclosure among general practitioners as second victim of a patient safety incident: a cross-sectional study in Flanders (Belgium).
Citation Text:
Neyens L, Stouten E, Vanhaecht K, et al. Open disclosure among general practitioners as second victim of a patient safety inciden…
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psnet.ahrq.gov/issue/society-maternal-fetal-medicine-special-statement-telemedicine-obstetrics-quality-and-safety
August 10, 2022 - Organizational Policy/Guidelines
Society for Maternal-Fetal Medicine Special Statement: telemedicine in obstetrics-quality and safety considerations.
Citation Text:
Healy A, Davidson C, Allbert J, et al. Society for Maternal-Fetal Medicine Special Statement: telemedicine in obstetrics-qu…
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psnet.ahrq.gov/issue/drivers-unprofessional-behaviour-between-staff-acute-care-hospitals-realist-review
July 24, 2024 - Review
Drivers of unprofessional behaviour between staff in acute care hospitals: a realist review.
Citation Text:
Aunger JA, Maben J, Abrams R, et al. Drivers of unprofessional behaviour between staff in acute care hospitals: a realist review. BMC Health Serv Res. 2023;23(1):1326. doi:1…
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psnet.ahrq.gov/issue/development-and-evaluation-institute-healthcare-improvement-global-trigger-tool
February 10, 2015 - Commentary
Development and evaluation of the Institute for Healthcare Improvement global trigger tool.
Citation Text:
Classen DC, Lloyd RC, Provost LP, et al. Development and Evaluation of the Institute for Healthcare Improvement Global Trigger Tool. J Patient Saf. 2008;4(3). doi:10.10…
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psnet.ahrq.gov/issue/patients-concerns-about-medical-errors-during-hospitalization
December 22, 2008 - Study
Classic
Patients' concerns about medical errors during hospitalization.
Citation Text:
Burroughs TE, Waterman AD, Gallagher TH, et al. Patients' concerns about medical errors during hospitalization. Jt Comm J Qual Patient Saf. 2007;33(1):5-14.
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psnet.ahrq.gov/issue/strengths-and-weaknesses-working-global-trigger-tool-method-retrospective-record-review-focus
March 24, 2012 - Study
Strengths and weaknesses of working with the Global Trigger Tool method for retrospective record review: focus group interviews with team members.
Citation Text:
Schildmeijer K, Nilsson L, Perk J, et al. Strengths and weaknesses of working with the Global Trigger Tool method for r…
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psnet.ahrq.gov/issue/wide-variation-and-overprescription-opioids-after-elective-surgery
April 24, 2018 - Study
Classic
Wide variation and overprescription of opioids after elective surgery.
Citation Text:
Thiels CA, Anderson SS, Ubl DS, et al. Wide Variation and Overprescription of Opioids After Elective Surgery. Ann Surg. 2017;266(4):564-573. doi:10.1097/SLA.00000…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-culture-survey-brazil-summary.html
August 01, 2024 - Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study
Summary of Survey Findings
Previous Page Next Page
Table of Contents
Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study
Introdu…
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psnet.ahrq.gov/issue/lawrence-d-dorr-surgical-techniques-technologies-award-running-two-rooms-does-not-compromise
July 29, 2020 - Study
The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running two rooms" does not compromise outcomes or patient safety in joint arthroplasty.
Citation Text:
Hamilton WG, Ho H, Parks NL, et al. The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running Two Ro…
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psnet.ahrq.gov/issue/delayed-rapid-response-team-activation-associated-increased-hospital-mortality-morbidity-and
March 16, 2022 - Study
Delayed rapid response team activation is associated with increased hospital mortality, morbidity, and length of stay in a tertiary care institution.
Citation Text:
Barwise A, Thongprayoon C, Gajic O, et al. Delayed Rapid Response Team Activation Is Associated With Increased Hospit…
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psnet.ahrq.gov/issue/missed-opportunities-diagnosis-lessons-learned-diagnostic-errors-primary-care
September 23, 2020 - Study
Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care.
Citation Text:
Goyder CR, Jones CHD, Heneghan CJ, et al. Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care. Br J Gen Pract. 2015;65(641):e838-e844. d…
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psnet.ahrq.gov/issue/patient-safety-climate-us-hospitals-variation-management-level
November 18, 2009 - Study
Classic
Patient safety climate in US hospitals: variation by management level.
Citation Text:
Singer SJ, Falwell A, Gaba DM, et al. Patient safety climate in US hospitals: variation by management level. Med Care. 2008;46(11):1149-56. doi:10.1097/MLR.0b013e…
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www.ahrq.gov/news/newsroom/case-studies/ktcoe33.html
October 01, 2014 - Iowa Medicaid Uses AHRQ Research, Data to Improve Quality
Search All Impact Case Studies
March 2010
As a result of participating in the Medicaid Medical Directors Learning Network—an AHRQ Knowledge Transfer project—the Iowa Medicaid Enterprise, in consultation with the Iowa Foundation for Medical Care, used…
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psnet.ahrq.gov/issue/medical-errors-us-pediatric-inpatients-chronic-conditions
November 04, 2014 - Study
Medical errors in US pediatric inpatients with chronic conditions.
Citation Text:
Ahuja N, Zhao W, Xiang H. Medical errors in US pediatric inpatients with chronic conditions. Pediatrics. 2012;130(4):e786-e793. doi:10.1542/peds.2011-2555.
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DOI Goog…
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psnet.ahrq.gov/issue/tenfold-medication-errors-5-years-experience-university-affiliated-pediatric-hospital
August 07, 2024 - Study
Tenfold medication errors: 5 years' experience at a university-affiliated pediatric hospital.
Citation Text:
Doherty C, Donnell CM. Tenfold medication errors: 5 years' experience at a university-affiliated pediatric hospital. Pediatrics. 2012;129(5):916-924. doi:10.1542/peds.2011-2…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-preventablereadm-primcare-es.pdf
March 01, 2020 - Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care: Executive Summary
Potentially Preventable Readmissions:
Conceptual Framework To Rethink the Role of
Primary Care
Executive Summary
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of H…
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psnet.ahrq.gov/issue/frequency-passive-ehr-alerts-icu-another-form-alert-fatigue
January 23, 2017 - Study
Frequency of passive EHR alerts in the ICU: another form of alert fatigue?
Citation Text:
Kizzier-Carnahan V, Artis KA, Mohan V, et al. Frequency of Passive EHR Alerts in the ICU: Another Form of Alert Fatigue? J Patient Saf. 2019;15(3):246-250. doi:10.1097/PTS.0000000000000270.
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psnet.ahrq.gov/issue/engaging-pediatric-resident-physicians-quality-improvement-through-resident-led-morbidity-and
November 16, 2022 - Study
Engaging pediatric resident physicians in quality improvement through resident-led morbidity and mortality conferences.
Citation Text:
Destino LA, Kahana M, Patel SJ. Engaging Pediatric Resident Physicians in Quality Improvement Through Resident-Led Morbidity and Mortality Conferen…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-creative-strategies-lee.pdf
June 02, 2025 - Creative Strategies to Improve Patient Care Experience - Part 4 Lee
What Is A Creative Idea?
Creative idea: An idea that is novel and useful
Creative
Improvement
Ideas
Process
Improvement
Promoting efficiency
by tweaking existing
routines
Patient Engagement
Enhancing patient
partnership by
knowing…
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psnet.ahrq.gov/issue/black-womens-maternal-health-insights-community-based-participatory-research-newark-new
June 21, 2023 - Study
Black women's maternal health: insights from community based participatory research in Newark, New Jersey.
Citation Text:
Kantor LM, Cruz N, Adams C, et al. Black women's maternal health: insights from community based participatory research in Newark, New Jersey. Behav Med. 2024;50…