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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - February 26, 2014
Communicating medication changes to community pharmacy post-discharge
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digital.ahrq.gov/ahrq-funded-projects/implementation-outcomes-health-it-program-vulnerable-diabetes-patients
January 01, 2023 - Implementation Outcomes of a Health Information Technology Program For Vulnerable Diabetes Patients
Project Final Report ( PDF , 332.07 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and d…
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digital.ahrq.gov/sites/default/files/docs/page/SuccessStory072012_Lapane.pdf
June 16, 2021 - Individualized, Multi-Media Materials in Spanish and English Help Seniors Manage Medications and Communicate with Clinician Team
“
”
—
9HRQ HE9LTH INFORM9TION TECHNOLOGY 1
9MBUL9TORY S9FETY 9ND QU9LITY • PCC
Individualized, Multi-Media Materials in Spanish and English Hel…
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psnet.ahrq.gov/node/49652/psn-pdf
May 01, 2012 - Double Dose at Transfer
May 1, 2012
Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/double-dose-transfer
The Case
A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department
(ED) for left lower extremity pain, swelling, and erythe…
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www.ahrq.gov/hai/cusp/toolkit/learn-defects.html
December 01, 2012 - Learn from Defects Tool
CUSP Toolkit
Health care organizations can increase the extent to which they learn from defects.
Problem statement: Health care organizations can increase the extent to which they learn from defects. We define this learning as reducing the probability that a future patient will be h…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.doc
June 02, 2025 - Learn From Defects Tool
Problem statement: Health care organizations can increase the extent to which they learn from defects. We define this learning as reducing the probability that a future patient will be harmed. Most often clinicians recover from mistakes by reducing risks to the patient who suffered a defect.
Wh…
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psnet.ahrq.gov/innovations
February 26, 2025 - Obstetrical Nursing
(1)
Palliative Care
(1)
Pharmacy
(3)
Community … Pharmacy
(1)
Hospital Pharmacy
(2)
Error Types
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/advisorycouncil/advisorycouncil.pdf
April 01, 2008 - heard stories of or actually
experienced errors, mistakes, and failures in hospitals, clinics, and pharmacies … created with a primary focus on patients who receive care in outpatient
settings, such as clinics, retail pharmacies … integrated delivery system in Wisconsin, has 13
hospitals, more than 100 clinics, more than 120 retail pharmacies … and practices, measured through
surveys (mail, phone, or e-mail), observational studies (at clinics,
pharmacies … safety council with patient and provider representatives
from hospitals, outpatient clinics, and retail pharmacies
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effectivehealthcare.ahrq.gov/sites/default/files/pulmonary-horizon-scan-high-impact-1312.pdf
December 01, 2013 - PULMONARY with "Discussions" in Exec Summary
AHRQ Healthcare Horizon Scanning System – Potential
High-Impact Interventions Report
Priority Area 13: Pulmonary Disease, Including Asthma
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither…
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www.ahrq.gov/sites/default/files/wysiwyg/data/SyH-DR-Sampling-Weighting-Synthetization-Methodologies.pdf
December 01, 2023 - Sampling, Weighting, and Synthetization Methodologies
Synthetic Healthcare Database
for Research (SyH-DR)
A Synthetic Nationally Representative
All-Payer Claims Database
SAMPLING, WEIGHTING, AND
SYNTHETIZATION METHODOLOGIES
AHRQ Publication No. 24-0019-4-EF
December 2023
SyH-DR i Methodologies
TABLE OF…
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digital.ahrq.gov/ahrq-funded-projects/improving-patient-safetyquality-health-information-technology-implementation/final-report
January 01, 2023 - Improving Patient Safety/Quality with HIT Implementation - Final Report
Citation
Reiling, J. Improving Patient Safety/Quality with HIT Implementation - Final Report. (Prepared by St. Joseph's Community Hospital under Grant No. UC1 HS015284). Rockville, MD: Agency for Healthcare Research and Quality, 2…
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/PatientCheckOut.pdf
December 18, 2021 - Patient Check Out
Patient Check Out
Fr
on
t D
es
k/
C
he
ck
O
ut
P
at
ie
nt Patient completes clinic
visit and appears at
checkout desk
Does patient
need to pick up
Rx at in-clinic
pharmacy?
Patient obtains
meds and returns
to checkout
counter
Select patient from
database …
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psnet.ahrq.gov/node/46160/psn-pdf
June 07, 2017 - ISMP Guidelines for Optimizing Safe Subcutaneous
Insulin Use in Adults.
June 7, 2017
Horsham, PA: Institute for Safe Medication Practices; May 2017.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-subcutaneous-insulin-use-adults
Insulin is a widely used medication that can contribute to serious patien…
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digital.ahrq.gov/sites/default/files/docs/resource/James_Veline_IQHIT_Q6_Adherence_and_Compliance_Patient_Letter.pdf
June 16, 2021 - Compliance Patient Letter
[Date]
[Recipient Name]
[Street Address]
[City, ST ZIP Code]
Dear [Recipient Name]:
With recent advancements in technology, our clinic is able to assist you with your blood
pressure medication in more ways than ever before.
Electronic prescribing gives our…
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www.ahrq.gov/ncepcr/research/health-literacy.html
October 01, 2024 - Health Literacy
Health literacy occurs when health information and services created for patients match with their capacity to find, understand, and use them. AHRQ provides the research, tools, and training to help healthcare organizations, leaders, and professionals improve health literacy and more effectively …
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psnet.ahrq.gov/node/47951/psn-pdf
April 24, 2019 - Safe medication management at ambulatory surgery
centers.
April 24, 2019
Ubaldi K. Safe Medication Management at Ambulatory Surgery Centers. AORN J. 2019;109(4):435-442.
doi:10.1002/aorn.12635.
https://psnet.ahrq.gov/issue/safe-medication-management-ambulatory-surgery-centers
Safe medication use can be challengin…
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psnet.ahrq.gov/node/42135/psn-pdf
April 22, 2013 - Interprofessional education in team communication:
working together to improve patient safety.
April 22, 2013
Brock DM, Abu-Rish E, Chiu C-R, et al. Interprofessional education in team communication: working
together to improve patient safety. BMJ Qual Saf. 2013;22(5):414-23. doi:10.1136/bmjqs-2012-000952.
https:/…
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psnet.ahrq.gov/node/36895/psn-pdf
March 10, 2011 - A systematic review of the performance characteristics of
clinical event monitor signals used to detect adverse drug
events in the hospital setting.
March 10, 2011
Handler S, Altman RL, Perera S, et al. A systematic review of the performance characteristics of clinical
event monitor signals used to detect adverse …
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psnet.ahrq.gov/node/37347/psn-pdf
March 28, 2012 - Recognition and management of potential drug-drug
interactions in patients on internal medicine wards.
March 28, 2012
Vonbach P, Dubied A, Beer JH, et al. Recognition and management of potential drug-drug interactions in
patients on internal medicine wards. Eur J Clin Pharmacol. 2007;63(11):1075-83.
https://psnet.…
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psnet.ahrq.gov/node/855002/psn-pdf
November 01, 2023 - Temporarily holding medication orders safely in order to
prevent patient harm.
November 1, 2023
ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4.
https://psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm
Process disconnects can cause administr…