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  1. Job Aid: Process Mapping (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-process-mapping.pdf
    June 02, 2025 - Job Aid: Process Mapping Primary Care Practice Facilitator Training Series 1 Job Aid: Process Mapping Overview Process mapping, also called workflow mapping, allows a practice to "see" an entire work process from beginning to end. When to use process mapping Use process mapping to help a p…

  2. Sounding the alarm. Nurses, organizations work to address alarm fatigue. | PSNet

    psnet.ahrq.gov/issue/sounding-alarm-nurses-organizations-work-address-alarm-fatigue
    July 19, 2017 - Newspaper/Magazine Article Sounding the alarm. Nurses, organizations work to address alarm fatigue. Citation Text: Trossman S. Sounding the alarm. Nurses, organizations work to address alarm fatigue. Am Nurs. 2013;45(5):1, 6-7. Copy Citation Format: Google Scholar PubMed…

  3. Cultural diversity: what role does it play in patient safety? | PSNet

    psnet.ahrq.gov/issue/cultural-diversity-what-role-does-it-play-patient-safety
    June 15, 2011 - Commentary Cultural diversity: what role does it play in patient safety? Citation Text: Ardoin KB, Wilson KB. Cultural diversity: what role does it play in patient safety? Nurs Womens Health. 2010;14(4):322-6. doi:10.1111/j.1751-486X.2010.01563.x. Copy Citation Format: DO…

  4. Leading your organization to high reliability. | PSNet

    psnet.ahrq.gov/issue/leading-your-organization-high-reliability
    August 18, 2021 - Commentary Leading your organization to high reliability. Citation Text: Kemper C, Boyle DK. Leading your organization to high reliability. Nurs Manag. 2009;40(4):14-18. doi:10.1097/01.NUMA.0000349684.24165.68. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNot…

  5. Reducing medication prescribing errors in a teaching hospital. | PSNet

    psnet.ahrq.gov/issue/reducing-medication-prescribing-errors-teaching-hospital
    August 02, 2010 - Study Reducing medication prescribing errors in a teaching hospital. Citation Text: Garbutt J, Milligan PE, McNaughton C, et al. Reducing medication prescribing errors in a teaching hospital. Jt Comm J Qual Patient Saf. 2008;34(9):528-536. Copy Citation Format: Google Sch…

  6. Are you listening...Are you really listening? | PSNet

    psnet.ahrq.gov/issue/are-you-listeningare-you-really-listening
    December 04, 2016 - Commentary Are you listening...Are you really listening? Citation Text: Denham CR, Dingman J, Foley M, et al. Are You Listening…Are You Really Listening? J Patient Saf. 2008;4(3):148-161. doi:10.1097/pts.0b013e318184db52. Copy Citation Format: DOI Google Scholar BibTeX En…

  7. Defining the PCMH | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/research/care-coordination/pcmh/define.html
    August 01, 2022 - Defining the PCMH The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place…

  8. A Randomized Field Study of a Leadership WalkRounds-Based Intervention. | PSNet

    psnet.ahrq.gov/issue/randomized-field-study-leadership-walkrounds-based-intervention
    May 24, 2016 - Book/Report A Randomized Field Study of a Leadership WalkRounds-Based Intervention. Citation Text: A Randomized Field Study of a Leadership WalkRounds-Based Intervention. Tucker AL, Singer SJ. Cambridge, MA: Harvard Business School; June 25, 2012. HBS Working Paper No. 12-113. Cop…

  9. PQMP Learning Collaborative | Agency for Healthcare Research and Quality

    www.ahrq.gov/pqmp/about/learning-collaborative.html
    September 01, 2021 - PQMP Learning Collaborative In late 2017, AHRQ—in partnership with the Centers for Medicare & Medicaid Services (CMS)—launched the Pediatric Quality Measures Program (PQMP) Learning Collaborative as a central component of the PQMP strategy to support the dissemination, implementation, performance monitoring, an…

  10. References | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-culture-survey-brazil-references.html
    August 01, 2024 - Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study References Previous Page   Table of Contents Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study Introduction Initial Approach…

  11. Confronting a colleague who covers up a medical error. | PSNet

    psnet.ahrq.gov/issue/confronting-colleague-who-covers-medical-error
    September 16, 2020 - Commentary Confronting a colleague who covers up a medical error. Citation Text: Brody H. Confronting a colleague who covers up a medical error. Am Fam Physician. 2006;73(7):1272, 1274. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnot…

  12. Ripped apart: medical misdiagnosis and malpractice. | PSNet

    psnet.ahrq.gov/issue/ripped-apart-medical-misdiagnosis-and-malpractice
    August 25, 2021 - Audiovisual Presentation Ripped apart: medical misdiagnosis and malpractice. Citation Text: Ripped apart: medical misdiagnosis and malpractice. Kast S, Gerr M, Black D, et al. “On the Record.” WYPR. August 3, 2021 Copy Citation Save Save to your library …

  13. Studying the technical work of emergency care. | PSNet

    psnet.ahrq.gov/issue/studying-technical-work-emergency-care
    September 29, 2010 - Commentary Studying the technical work of emergency care. Citation Text: Nemeth CP, Cook RI, Wears RL. Studying the technical work of emergency care. Ann Emerg Med. 2007;50(4):384-6. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

  14. Disclosure and apology: nursing and risk management working together. | PSNet

    psnet.ahrq.gov/issue/disclosure-and-apology-nursing-and-risk-management-working-together
    August 21, 2015 - Commentary Disclosure and apology: nursing and risk management working together. Citation Text: Russell D. Disclosure and apology: Nursing and risk management working together. Nurs Manage. 2018;49(6):17-19. doi:10.1097/01.NUMA.0000533773.14544.e2. Copy Citation Format: DOI…

  15. Understanding communication during hospitalist service changes: a mixed methods study. | PSNet

    psnet.ahrq.gov/issue/understanding-communication-during-hospitalist-service-changes-mixed-methods-study
    December 14, 2022 - Study Understanding communication during hospitalist service changes: a mixed methods study. Citation Text: doi:10.1002/jhm.523. Copy Citation Format: DOI BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Save …

  16. Current and emerging infectious risks of blood transfusions. | PSNet

    psnet.ahrq.gov/issue/current-and-emerging-infectious-risks-blood-transfusions
    June 09, 2021 - Study Current and emerging infectious risks of blood transfusions. Citation Text: Busch MP, Kleinman SH, Nemo GJ. Current and emerging infectious risks of blood transfusions. JAMA. 2003;289(8):959-62. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNo…

  17. Concurrent and Overlapping Surgeries: Additional Measures Warranted. | PSNet

    psnet.ahrq.gov/issue/concurrent-and-overlapping-surgeries-additional-measures-warranted
    August 17, 2022 - Book/Report Concurrent and Overlapping Surgeries: Additional Measures Warranted. Citation Text: Concurrent and Overlapping Surgeries: Additional Measures Warranted. US Senate Finance Committee. December 6, 2016. Copy Citation Save Save to your library Print …

  18. Appendix 9: Back to Basics | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/clabsi-tools/appendix-9.html
    March 01, 2018 - Appendix 9: Back to Basics Tools for Reducing Central Line-Associated Blood Stream Infections These tools will help your unit implement evidence-based practices and eliminate central line-associated blood stream infections (CLABSI). When used with the CUSP (Comprehensive Unit-based Safety Program) Toolkit, th…

  19. Operating Room Briefing and Debriefing Audit Tool | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/or-briefing-audit.html
    December 01, 2017 - Operating Room Briefing and Debriefing Audit Tool AHRQ Safety Program for Surgery Introduction Problem Statement One of the strongest determinants of safety culture is whether local and hospital leadership respond to staff patient safety concerns. Frontline providers understand patient safety …

  20. Implementation of patient safety initiatives in US hospitals. | PSNet

    psnet.ahrq.gov/issue/implementation-patient-safety-initiatives-us-hospitals
    December 12, 2014 - Commentary Implementation of patient safety initiatives in US hospitals. Citation Text: McFadden KL, Stock GN, Gowen CR. Implementation of patient safety initiatives in US hospitals. Int J Oper Prod Manag. 2006;26(3):326-347. doi:10.1108/01443570610651052. Copy Citation Format: …
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