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psnet.ahrq.gov/node/33870/psn-pdf
November 01, 2018 - which way you cut it, time costs money, and
the money must come from a health care system or health plan
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psnet.ahrq.gov/node/49770/psn-pdf
September 01, 2016 - Without a detailed error-prevention plan implemented for
each high-alert medication or medication class
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schyve.pdf
June 02, 2025 - One of these complexities is that the “systems” we describe or plan are really
only mental models of
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
April 01, 2025 - Put an audit plan into place to track that measure.
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
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psnet.ahrq.gov/node/33623/psn-pdf
December 01, 2005 - Perhaps we need to incorporate a
Plan-Do-Study-Act (PDSA) cycle for public policy.(8) In any case, the
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psnet.ahrq.gov/node/49791/psn-pdf
April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the
Preventable
April 1, 2017
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
The Case
An 84-year-old wo…
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psnet.ahrq.gov/node/49463/psn-pdf
October 14, 2004 - Moved Too Soon
October 1, 2004
Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/moved-too-soon
The Case
A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours
after arriving, while the patient was still groggy from anesthesia, a nurs…
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psnet.ahrq.gov/node/33876/psn-pdf
August 01, 2018 - Building a Safety Program in a Vast Health Care Network
March 1, 2019
Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
Perspective
Background
As hospital-based health care in the United …
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/nh/about/measures-nursing-home-family-member-609.pdf
December 28, 2017 - Patient Experience Measures from the CAHPS Nursing Home Family Member Survey
Patient Experience Measures from the CAHPS Nursing Home Family Member Survey
CAHPS® Nursing Home Family Member Survey
Patient Experience Measures from the
CAHPS® Nursing Home Family Member
Survey
Document No. 609
Updated 12/2…
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www.ahrq.gov/teamstepps-program/curriculum/situation/teach/two-day.html
February 01, 2024 - Offering Two-Day Training Content
If you are teaching the Situation Monitoring Module as part of a two-day training, you should be able to perform all the activities noted below in around 60 minutes. Components to use in this section include:
Introductory Teamwork Exercise #2 : 8 minutes
Objectives and Int…
-
psnet.ahrq.gov/node/49414/psn-pdf
September 01, 2003 - Making Do
September 1, 2003
Bradley LD. Making Do. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/making-do
The Case
A 56-year-old female with dysfunctional uterine bleeding and possible retained intrauterine device (IUD)
was scheduled for elective hysteroscopy and dilation and curettage (D&C). Of note, sh…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-slides.pptx
November 01, 2019 - mechanism for daily review of antibiotics; poor written or verbal communication during handoffs; treatment plan
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www.ahrq.gov/research/publications/pubcomguide/pcguide5.html
July 01, 2025 - To ensure OC has sufficient time to plan outreach efforts, AHRQ staff must notify OC as soon as they
-
psnet.ahrq.gov/primer/digital-health-literacy
August 30, 2023 - Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan
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cdsic.ahrq.gov/cdsic/2024-annual-meeting-viewpoint
September 18, 2024 - :
Skip to main content
HHS.gov
Menu
Main navigation
CDS Home
CDS Innovation Collaborative
An official website of the Department of Health & Human Services
…
-
digital.ahrq.gov/ahrq-funded-projects/clinical-decision-support-innovation-collaborative-cdsic
January 01, 2025 - Through an evidence-based approach and dissemination plan, this research has the potential to increase
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psnet.ahrq.gov/primer/computerized-provider-order-entry
March 15, 2025 - Computerized Provider Order Entry
Citation Text:
Computerized Provider Order Entry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/The_Case_for_Improving_Patient_Experience_-2011_10_01_Transcript.pdf
January 01, 2011 - CAHPS QI The Case for Improving Patient Experience
The Case for Improving Patient Experience
October 2011 Podcast
Speaker
Larry Morrissey, MD, Medical Director of Quality Improvement, Stillwater Medical Group
Moderator
Carla Zema, PhD, Consultant, CAHPS User Network; Assistant Professor of Economics an…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-erepguide.pdf
February 10, 2014 - to see the value of the reports, judge the accuracy of the reports,
and use them to help make care plan … and the dietitian attends, the
team can discuss this issue immediately and promptly update care
plan … cause for
lack of pressure ulcer healing and support team decisionmaking
about the current treatment plan … Were the interventions in the care plan developed by a
multidisciplinary team? … Were the interventions written in the care plan carried
out? Why or why not?
e.