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psnet.ahrq.gov/issue/how-business-intelligence-can-improve-patient-safety
June 27, 2018 - Newspaper/Magazine Article
How business intelligence can improve patient safety.
Citation Text:
How business intelligence can improve patient safety. Wanless S, McManaway J. Metaphor Analytics. August 30, 2005.
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/ap4.html
August 01, 2022 - Communication Assessment Guide: Appendix 4
References
O'Keefe BJ, Lambert BL, Lambert CA. Conflict and communication in a research and development unit. In: Sypher BD, ed. Case studies in organizational communication 2: Perspectives on contemporary work life . New York: Guilford; 1997:31-52.
O'Keefe BJ…
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/ahcp-template-sp.html
March 01, 2025 - Re-Engineered Discharge (RED) Toolkit
Template for Manual Creation of the AHCP: Spanish-Speaking Patients
Previous Page Next Page
Table of Contents
Re-Engineered Discharge (RED) Toolkit
Tool 1: Overview
Tool 2: How To Begin the Re-engineered Discharge Implementation at Your Hospital
How CMS Me…
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psnet.ahrq.gov/web-mm/failure-reevaluate
February 01, 2014 - Failure to Reevaluate
Citation Text:
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room
Citation Text:
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…
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psnet.ahrq.gov/web-mm/surprise-wire
July 15, 2020 - Surprise Wire
Citation Text:
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/72693/psn-pdf
January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room
– Mixing Up the Ampules
January 29, 2021
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
The Case
A…
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integrationacademy.ahrq.gov/news-and-events/news/workforce-innovation-behavioral-health-integration-insights-idaho-health
October 28, 2024 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
Contact Us
Español
FAQs
Email Updates
The Academy
Integrating Behavioral Health & Primary Care
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psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
October 01, 2003 - Hospital Admission Due to High-Dose Methotrexate Drug Interaction
Citation Text:
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/110-ss-lfd-sample.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects Tool—Sample
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
What Is a Defect?
A defect is any clinical or operational event or situation that you would not want to happen again. This could include i…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
October 01, 2018 - visit
Results from lab
or imaging test
not available
when needed
Information
exchange
problems with
pharmacies … visit
Results from lab
or imaging test
not available
when needed
Information
exchange
problems with
pharmacies … list not getting updated during their visit, and 12%
reported an information exchange problem with pharmacies … visit
Results from lab
or imaging test
not available
when needed
Information
exchange
problems with
pharmacies … fourfold for medication lists not being updated; threefold for information exchange problems
with pharmacies
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2022-hsops-wps-study-report.pdf
January 01, 2022 - 2022 Updated Results for the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Workplace Safety Supplemental Items for Hospitals
2022 Updated Results for the AHRQ
Surveys on Patient Safety CultureTM (SOPS®)
Workplace Safety Supplemental Item Set for
Hospitals
Prepared for:
Agency for Healthcare Research and Qua…
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www.ahrq.gov/sites/default/files/2024-01/jack-report.pdf
January 01, 2024 - Final Progress Report: Re-engineering the Hospital Discharge for Patient Safety--Safe Practices Implementation Challenge Grant
Final Report
Re-engineering the Hospital Discharge for Patient Safety
Safe Practices Implementation Challenge Grant
Dates of Project: 09/30/03-09/29/04
Federal Project Officer: Deborah Que…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/French.pdf
April 27, 2004 - Outpatient Benzodiazepine Prescribing, Adverse Events, and Costs
185
Outpatient Benzodiazepine Prescribing,
Adverse Events, and Costs
Dustin D. French, Andrea M. Spehar, Robert R. Campbell,
Polly Palacios, Roy W. Coakley, Nicholas Coblio, Heidi Means,
Dennis C. Werner, David M. Angaran
Abstract
Objectives…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
January 01, 2003 - Development and Validation of the Medication Administration Error Reporting Survey
475
Development and Validation of the Medication
Administration Error Reporting Survey
Bonnie J. Wakefield, Tanya Uden-Holman, Douglas S. Wakefield
Abstract
Analysis of medication errors can lead to system improvement and reduc…
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digital.ahrq.gov/ahrq-funded-projects/health-information-technology-and-improving-medication-use
January 01, 2023 - Health Information Technology and Improving Medication Use
Project Final Report ( PDF , 368.03 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Bad Writing, Wrong Medication
*
*
Source and Credits
This presentation is based on the April 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Beth Devine, PharmD, MBA, PhD
University of Washingto…
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psnet.ahrq.gov/node/49603/psn-pdf
June 01, 2010 - Fatal Error in Neonate: Does "Just Culture" Provide an
Answer?
June 1, 2010
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
Case Objectives
Describe the just culture approach to in…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/3-bestpractices-web-sopssurveys-famolaro.pdf
September 01, 2020 - Surveys
Hospital
13
14
Response Rates by Mode
Survey
Mode Hospital Medical
Office
Nursing
Home
Community … Pharmacy
Paper only 57% 90% 60% 93%
Web only 53% 71% 55% 63%
Use of Mobile Devices in SOPS Pilot
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024335-rangachari-final-report-2018.pdf
January 01, 2018 - company that supports e-prescription, the electronic transmission of prescriptions between HCOs and
pharmacies … According to the US DHHS, in 2014, 96% of US community pharmacies used the Surescripts
network. … At AU Health, it was determined that 90% of patients fill their prescriptions at pharmacies that
participate