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  1. digital.ahrq.gov/developing-and-testing-quality-measures-interoperable-electronic-health-records
    January 01, 2023 - Developing and Testing Quality Measures for Interoperable Electronic Health Records Your browser does not support inline frames. Please go to https://youtu.be/-0H1ENHAFew to view the video. Principal Investigator: Rainu Kaushal  (Grant No. R18 HS017067) [6 min., 51 sec.] The story features …
  2. digital.ahrq.gov/ahrq-funded-projects/surveillance-adverse-drug-events-ambulatory-pediatrics/citation/informatics
    January 01, 2023 - The informatics opportunities at the intersection of patient safety and clinical informatics. Citation Kilbridge PM, Classen DC. The informatics opportunities at the intersection of patient safety and clinical informatics. J Am Med Inform Assoc 2008 Jul-Aug;15(4):397-407. Link Kilbridge PM, Cl…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41520/psn-pdf
    December 12, 2012 - Information distortion in physicians' diagnostic judgments. December 12, 2012 Kostopoulou O, Russo E, Keenan G, et al. Information distortion in physicians' diagnostic judgments. Med Decis Making. 2012;32(6):831-9. doi:10.1177/0272989X12447241. https://psnet.ahrq.gov/issue/information-distortion-physicians-diagnos…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35699/psn-pdf
    November 18, 2011 - Improving the Reliability of Health Care. November 18, 2011 Nolan T, Resar R, Haraden C, et al. Boston, MA: Institute for Healthcare Improvement; 2004. https://psnet.ahrq.gov/issue/improving-reliability-health-care This report shares a three-step model for applying reliability principles to health care. The element…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36031/psn-pdf
    June 21, 2006 - Patient safety, systems design and ergonomics. June 21, 2006 Buckle P, Clarkson PJ, Coleman R, et al. Patient safety, systems design and ergonomics. Appl Ergon. 2006;37(4):491-500. doi:10.1016/j.apergo.2006.04.016. https://psnet.ahrq.gov/issue/patient-safety-systems-design-and-ergonomics The authors discuss design…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36253/psn-pdf
    November 28, 2018 - Medication Reconciliation Handbook, 2nd edition. November 28, 2018 American Society of Health-System Pharmacists, Joint Commission on Accreditation of Healthcare Organizations. Oakbrook Terrace IL; Joint Commission Resources: 2009. ISBN 9781599403090. https://psnet.ahrq.gov/issue/medication-reconciliation-handbook-…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42646/psn-pdf
    October 23, 2013 - System-related factors contributing to diagnostic errors. October 23, 2013 Thammasitboon S, Thammasitboon S, Singhal G. System-related factors contributing to diagnostic errors. Curr Probl Pediatr Adolesc Health Care. 2013;43(9):242-7. doi:10.1016/j.cppeds.2013.07.004. https://psnet.ahrq.gov/issue/system-related-fa…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37611/psn-pdf
    February 15, 2011 - SBAR for patients. February 15, 2011 Denham CR. SBAR for Patients. J Patient Saf. 2008;4(1). doi:10.1097/pts.0b013e2181660c06. https://psnet.ahrq.gov/issue/sbar-patients This commentary presents information and background on the standardized communication process known as SBAR (situation, background, assessment, a…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34911/psn-pdf
    April 21, 2005 - Patient Safety Essentials for Health Care. 5th ed. April 21, 2005 Oakbrook Terrace, IL: Joint Commission Resources; 2009. https://psnet.ahrq.gov/issue/4th-ed-patient-safety-essentials-health-care This book provides a complete overview of the Joint Commission's National Patient Safety Goals and how to apply them in…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39961/psn-pdf
    March 08, 2015 - When errors occur. March 8, 2015 Wetzel TG. When errors occur, 'I'm sorry' is a big step, but just the first. Hospitals & health networks. 2010;84(10):41-2, 44, 2. https://psnet.ahrq.gov/issue/when-errors-occur This article describes how hospital responses to adverse events have affected disclosure process strate…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39224/psn-pdf
    August 11, 2015 - Diagnostic error and clinical reasoning. August 11, 2015 Norman GR, Eva KW. Diagnostic error and clinical reasoning. Med Educ. 2010;44(1):94-100. doi:10.1111/j.1365-2923.2009.03507.x. https://psnet.ahrq.gov/issue/diagnostic-error-and-clinical-reasoning This article reviews evidence on the cognitive origins of diag…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37284/psn-pdf
    December 30, 2014 - Medication tracers: a systems approach to medication safety. December 30, 2014 Hendrick EC, Montanya KR, Griffith NL. Medication Tracers: A Systems Approach to Medication Safety. Hosp Pharm. 2010;42(10):916-920. doi:10.1310/hpj4210-916. https://psnet.ahrq.gov/issue/medication-tracers-systems-approach-medication-sa…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36941/psn-pdf
    July 19, 2017 - ACOG Committee Opinion #508: disruptive behavior. July 19, 2017 ACOG Committee Opinion No. 508: disruptive behavior. Obstet Gynecol. 2011;118(4):970-2. doi:10.1097/AOG.0b013e3182358acc. https://psnet.ahrq.gov/issue/acog-committee-opinion-508-disruptive-behavior This guideline outlines important areas of concern an…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38092/psn-pdf
    September 24, 2008 - Time out: an analysis. September 24, 2008 Dillon KA. Time out: an analysis. AORN J. 2008;88(3):437-442. doi:10.1016/j.aorn.2008.03.003. https://psnet.ahrq.gov/issue/time-out-analysis This article discusses the reasons for utilizing the Joint Commission Universal Protocol for time outs and describes a process for i…
  15. www.ahrq.gov/news/rfi-diagnostic-excellence.html
    February 01, 2025 - AHRQ Seeks Input on Measures of Diagnostic Excellence A Request for Informatio n published by AHRQ requests public comments by March 10 on the development of measures of diagnostic excellence that may be calculated using administrative data or electronic health record data. The purpose of diagnostic excellence…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38911/psn-pdf
    September 09, 2009 - Radiology failure mode and effect analysis: what is it? September 9, 2009 Abujudeh H, Kaewlai R. Radiology failure mode and effect analysis: what is it? Radiology. 2009;252(2):544-50. doi:10.1148/radiol.2522081954. https://psnet.ahrq.gov/issue/radiology-failure-mode-and-effect-analysis-what-it This article introdu…
  17. digital.ahrq.gov/sites/default/files/docs/citation/u18hs027557-dykes-final-report-2022.pdf
    January 01, 2022 - current-state fall prevention practices in clinics so that we may identify the gaps and needs in those processes … virtual workflow observation where the provider would demonstrate the activities, steps, and thought processes … Additionally, if manual processes exist in addition to automated functions with the CDS, time can be
  18. digital.ahrq.gov/sites/default/files/docs/citation/r21hs027248-kowalkowski-final-report-2023.pdf
    January 01, 2023 - session to engage end users (patients, caregivers, and providers) early in app ideation and development processes
  19. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
    April 09, 2004 - New systems or processes can be implemented and measured to determine their effectiveness for reducing
  20. www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-31-facilitating-panel-management.pdf
    September 01, 2015 - Processes need to be established in the practice to ensure the sustainability of managing patient panels … For example, training materials and job descriptions need to be established with panel management processes