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psnet.ahrq.gov/node/41976/psn-pdf
March 11, 2013 - Moving beyond readmission penalties: creating an ideal
process to improve transitional care.
March 11, 2013
Burke RE, Kripalani S, Vasilevskis EE, et al. Moving beyond readmission penalties: creating an ideal
process to improve transitional care. J Hosp Med. 2013;8(2):102-9. doi:10.1002/jhm.1990.
https://psnet.ahr…
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psnet.ahrq.gov/node/34960/psn-pdf
June 22, 2009 - Making hospital care safer and better: the structure-
process connection leading to adverse events.
June 22, 2009
El-Jardali F, Lagacé M. Making hospital care safer and better: the structure-process connection leading to
adverse events. Healthc Q. 2005;8(2):40-8.
https://psnet.ahrq.gov/issue/making-hospital-care-s…
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psnet.ahrq.gov/node/41781/psn-pdf
October 24, 2012 - Designing for Patient Safety: Developing Methods to
Integrate Patient Safety Concerns in the Design Process.
October 24, 2012
Joseph A, Quan X, Taylor E, Jelen M. Concord, CA: Center for Health Design; 2012.
https://psnet.ahrq.gov/issue/designing-patient-safety-developing-methods-integrate-patient-safety-
co…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-guidance-topics_methods.pdf
January 01, 2010 - Methods Guide for Comparative Effectiveness Reviews
Identifying, Selecting, and Refining Topics
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
www.ahrq.gov
…
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www.ahrq.gov/sites/default/files/2024-12/lin-report.pdf
January 01, 2024 - Final Progress Report: Measurement of Decision Quality in Coronary Artery Disease
Measurement of Decision Quality in Coronary Artery Disease
Grace A. Lin, MD, MAS, Principal Investigator
R. Adams Dudley, MD, MBA, Mentor
Rita F. Redberg, MD, MSc, Co-mentor
Organization: University of California, San Francisco
…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/problem
January 01, 2023 - Problem Solving
Kepner-Tregoe Matrix
Description
A Kepner-Tregoe matrix is used to find causes of a problem. It isolates the who, what, when, where, and how aspects of an event, keeping the focus on the elements that have an impact on the event and eliminating the elements tha…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/risk
January 01, 2023 - Risk Assessment
Cause-and-Effect Diagram
Description
Cause-and-effect diagrams provide a visual means of conveying all suspected and possible causes and consequences of a specific problem.
Contingency Diagram
Description
The contingency diagram …
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-safe-csection.html
July 01, 2023 - Labor and Delivery Unit Safety: Safe Cesarean Section
AHRQ Safety Program for Perinatal Care
Purpose of the tool: This tool describes the key perinatal safety elements related to safe cesarean section. The key elements are presented within the framework of the Comprehensive Unit-based Safety Prog…
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/reid.html
October 01, 2015 - Transforming Primary Care: Evaluating the Spread of Group Health’s Medical Home
Principal Investigator: Robert Reid, MD, MPH, PhD
Institution: Group Health Cooperative
AHRQ Grant Number: R18 HS019129
Number and Type of Practices
This project included 26 practices in an integrated…
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www.ahrq.gov/news/newsroom/case-studies/ktcquips90.html
October 01, 2014 - Georgia Hospitals Improve Medication Reconciliation Process With AHRQ Toolkit
Search All Impact Case Studies
April 2012
After participating in AHRQ-sponsored learning sessions and provider support calls, Allina/GMCF, the Quality Improvement Organization (QIO) for Georgia, in conjunction with the Georgia Hos…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/impguide.html
November 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training
Implementation of the Falls Prevention Reports
Note: This part of the training consists of interactive exercises and does not have any slides. If you are not part of a formal training, please read all these materials, prin…
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psnet.ahrq.gov/node/47226/psn-pdf
August 01, 2018 - Development of a standardized, citywide process for
managing smart-pump drug libraries.
August 1, 2018
Walroth TA, Smallwood S, Arthur KJ, et al. Development of a standardized, citywide process for managing
smart-pump drug libraries. Am J Health Syst Pharm. 2018;75(12):893-900. doi:10.2146/ajhp170262.
https://psne…
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psnet.ahrq.gov/node/42396/psn-pdf
July 31, 2013 - Developing and implementing a standardized process for
Global Trigger Tool application across a large health
system.
July 31, 2013
Garrett PR, Sammer C, Nelson A, et al. Developing and implementing a standardized process for global
trigger tool application across a large health system. Jt Comm J Qual Saf. 2013;39(…
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psnet.ahrq.gov/node/44346/psn-pdf
March 18, 2016 - Developing a primary care patient measure of safety (PC
PMOS): a modified Delphi process and face validity
testing.
March 18, 2016
Hernan AL, Giles SJ, O'Hara JK, et al. Developing a primary care patient measure of safety (PC PMOS): a
modified Delphi process and face validity testing. BMJ Qual Saf. 2016;25(4):273-…
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psnet.ahrq.gov/node/854986/psn-pdf
November 01, 2023 - Implementing a safer and more reliable system to monitor
test results at a teaching university-affiliated facility in a
family medicine group: a quality improvement process
report.
November 1, 2023
Dorimain M-V, Plouffe-Malette M, Paquette M, et al. Implementing a safer and more reliable system to
monitor test re…
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www.ahrq.gov/patient-safety/settings/hospital/match/figure-2txt.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Figure 2: Medication Reconciliation Upon Discharge High Level Process Map Before Redesign (Text Description)
Previous Page Next Page
Table of Contents
Medications at Transitions and Clinical Handoffs (MATC…
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www.ahrq.gov/es/patient-safety/settings/hospital/match/figure-2txt.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Figure 2: Medication Reconciliation Upon Discharge High Level Process Map Before Redesign (Text Description)
Previous Page Next Page
Table of Contents
Medications at Transitions and Clinical Handoffs (MATC…
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psnet.ahrq.gov/node/72751/psn-pdf
February 17, 2021 - The critical need for nursing education to address the
diagnostic process.
February 17, 2021
Gleason KT, Harkless G, Stanley J, et al. The critical need for nursing education to address the diagnostic
process. Nurs Outlook. 2021;69(3):362-369. doi:10.1016/j.outlook.2020.12.005.
https://psnet.ahrq.gov/issue/critica…
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psnet.ahrq.gov/node/40478/psn-pdf
June 13, 2011 - Evaluating the medication process in the context of CPOE
use: the significance of working around the system.
June 13, 2011
Niazkhani Z, Pirnejad H, van der Sijs H, et al. Evaluating the medication process in the context of CPOE
use: the significance of working around the system. Int J Med Inform. 2011;80(7):490-506…
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psnet.ahrq.gov/node/42617/psn-pdf
January 24, 2018 - Improving Your Office Testing Process: A Step by Step
Guide for Rapid-Cycle Patient Safety and Quality
Improvement.
January 24, 2018
Rockville, MD: Agency for Healthcare Research and Quality; January 2018.
https://psnet.ahrq.gov/issue/improving-your-office-testing-process-step-step-guide-rapid-cycle-patient-
safe…