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psnet.ahrq.gov/node/60267/psn-pdf
March 01, 2021 - Affordable Housing Community Offers Seniors Onsite
Health Care Coordination and Support, Reducing Hospital
Admissions and Falls and Improving Resident Health
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-h…
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psnet.ahrq.gov/node/46704/psn-pdf
December 04, 2018 - Surveying care teams after in-hospital deaths to identify
preventable harm and opportunities to improve advance
care planning.
December 4, 2018
Lucier D, Folcarelli P, Totte C, et al. Surveying Care Teams after in-Hospital Deaths to Identify Preventable
Harm and Opportunities to Improve Advance Care Planning. Jt C…
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psnet.ahrq.gov/node/39960/psn-pdf
September 19, 2016 - Respectful Management of Serious Clinical Adverse
Events. Second Edition.
September 19, 2016
Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Healthcare Improvement;
2011.
https://psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition
This white paper e…
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psnet.ahrq.gov/node/46936/psn-pdf
April 11, 2018 - You've detailed your last wishes, but doctors may not see
them.
April 11, 2018
Lamas D.
https://psnet.ahrq.gov/issue/youve-detailed-your-last-wishes-doctors-may-not-see-them
Advance care planning can affect patient safety if the information is unheeded, unavailable, or unread.
Reporting on a physician's experienc…
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psnet.ahrq.gov/node/50700/psn-pdf
January 01, 2020 - Developing health care organizations that pursue learning
and exploration of diagnostic excellence: an action plan.
December 4, 2019
Singh H, Upadhyay DK, Torretti D. Developing Health Care Organizations That Pursue Learning and
Exploration of Diagnostic Excellence: An Action Plan. Acad Med. 2020;95(8):1172-1178.
…
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psnet.ahrq.gov/node/34692/psn-pdf
February 10, 2011 - The economic consequences of medical injuries:
implications for a no-fault insurance plan.
February 10, 2011
Johnson WG, Brennan TA, Newhouse JP, et al. The economic consequences of medical injuries.
Implications for a no-fault insurance plan. JAMA. 1992;267(18):2487-92.
https://psnet.ahrq.gov/issue/economic-conse…
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psnet.ahrq.gov/node/42439/psn-pdf
November 23, 2016 - Guide to Patient and Family Engagement in Hospital
Quality and Safety.
November 23, 2016
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
https://psnet.ahrq.gov/issue/guide-patient-and-family-engagement-hospital-quality-and-safety
Studies have shown that a surprisingly large proportion of hosp…
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psnet.ahrq.gov/node/33899/psn-pdf
April 16, 2018 - Quick Tips—When Planning for Surgery.
April 16, 2018
Agency for Health Research Research and Quality; AHRQ
https://psnet.ahrq.gov/issue/quick-tips-when-planning-surgery
A list of quick tips and questions to aid anyone who is preparing for surgery.
https://psnet.ahrq.gov/issue/quick-tips-when-planning-surgery
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psnet.ahrq.gov/node/35102/psn-pdf
November 04, 2015 - Plan aims to cut hospital deaths.
November 4, 2015
Appleby J.
https://psnet.ahrq.gov/issue/plan-aims-cut-hospital-deaths
This article reports on the 100,000 Lives Campaign and its mission, highlighting improvements in two
hospitals that have joined the campaign.
https://psnet.ahrq.gov/issue/plan-aims-cut-hospital…
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psnet.ahrq.gov/node/42006/psn-pdf
January 30, 2013 - Strong for Surgery.
January 30, 2013
American College of Surgeons.
https://psnet.ahrq.gov/issue/strong-surgery
This Web site offers resources for both practitioners and patients to optimize safety through pre-procedure
planning.
https://psnet.ahrq.gov/issue/strong-surgery
https://psnet.ahrq.gov/issue/quick-tips-w…
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psnet.ahrq.gov/node/38153/psn-pdf
October 15, 2008 - Geisinger Health System's plan to fix America's health
care.
October 15, 2008
Carbonara P. Fast Company. October 2008.
https://psnet.ahrq.gov/issue/geisinger-health-systems-plan-fix-americas-health-care
This magazine article describes how one health system is using an evidence-based, pay-for-performance
program t…
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psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
January 01, 2019 - Spotlight
Spotlight
"Do You Want Everything Done?":
Clarifying Code Status
Source and Credits
• This presentation is based on the December 2019
AHRQ WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Karl Steinberg MD, CMD, HMDC & Thaddeus
M…
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psnet.ahrq.gov/node/33950/psn-pdf
February 05, 2018 - Quick Tips--When Planning for Surgery.
February 5, 2018
Rockville, MD: Agency for Health Care Policy and Research; 2005. AHRQ Pub. No. 01-0040d.
https://psnet.ahrq.gov/issue/quick-tips-when-planning-surgery-0
This AHRQ brochure provides practical advice for patients facing non-emergent surgery, to help them be
gen…
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psnet.ahrq.gov/node/37905/psn-pdf
December 19, 2018 - Why Hospitals Should Fly: The Ultimate Flight Plan to
Patient Safety and Quality Care.
December 19, 2018
Nance JJ. Boseman, MT: Second River Healthcare Press; 2008. ISBN: 9780974386058.
https://psnet.ahrq.gov/issue/why-hospitals-should-fly-ultimate-flight-plan-patient-safety-and-quality-care
This book describes si…
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psnet.ahrq.gov/node/39612/psn-pdf
June 16, 2010 - National Action Plan to Improve Health Literacy.
June 16, 2010
Washington, DC: United States Department of Health and Human Services; 2010.
https://psnet.ahrq.gov/issue/national-action-plan-improve-health-literacy
This report presents goals for improved health literacy in the United States and recommends pra…
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psnet.ahrq.gov/node/49560/psn-pdf
April 01, 2008 - The Wrongful Resuscitation
April 1, 2008
Teno JM. The Wrongful Resuscitation. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wrongful-resuscitation
The Case
An 80-year-old man with diabetes, peripheral vascular disease, bilateral below-the-knee amputations, and
poor quality of life had previously been r…
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psnet.ahrq.gov/node/43607/psn-pdf
October 15, 2014 - Dallas Ebola case shows even sound plans can fail
spectacularly.
October 15, 2014
Loftis RL. Dallas Morning News. October 5, 2014.
https://psnet.ahrq.gov/issue/dallas-ebola-case-shows-even-sound-plans-can-fail-spectacularly
Guidelines and rules are developed to help augment safety, but they cannot guarantee it. Th…
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psnet.ahrq.gov/node/45191/psn-pdf
June 01, 2016 - Rating hospitals by the stars: the feds' latest plan to
measure quality is the most controversial.
June 1, 2016
Rau J. Washington Post. May 17, 2016.
https://psnet.ahrq.gov/issue/rating-hospitals-stars-feds-latest-plan-measure-quality-most-controversial
Collecting data to meet quality measurement requirements adds…
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psnet.ahrq.gov/node/46787/psn-pdf
October 15, 2018 - Institute for Safe Medication Practices International
Mentorship Program.
October 15, 2018
Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/institute-safe-medication-practices-international-mentorship-program
Structured interaction with a wide variety of experts and environments enables medica…
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psnet.ahrq.gov/node/44735/psn-pdf
January 06, 2016 - Quality and patient safety teams in the perioperative
setting.
January 6, 2016
Serino MF. Quality and Patient Safety Teams in the Perioperative Setting. AORN J. 2015;102(6):617-28.
doi:10.1016/j.aorn.2015.10.006.
https://psnet.ahrq.gov/issue/quality-and-patient-safety-teams-perioperative-setting
Team effectivenes…