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psnet.ahrq.gov/issue/health-literacy-and-communication-quality-health-care-organizations
November 26, 2014 - Study
Health literacy and communication quality in health care organizations.
Citation Text:
Wynia M, Osborn CY. Health literacy and communication quality in health care organizations. J Health Commun. 2010;15 Suppl 2:102-15. doi:10.1080/10810730.2010.499981.
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/problem-solving-slides.html
June 01, 2017 - Management Practices for Sustainability Module 3: Problem Solving and Escalation
Slide 1: Management Practices for Sustainability Module 3: Problem Solving and Escalation
Management Practices for Sustainability
Module 3: Problem Solving and Escalation
Slide 2: A Frontline Management System To Promote Sa…
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psnet.ahrq.gov/issue/transdisciplinary-team-acting-evidence-through-analyses-moot-malpractice-cases
November 03, 2021 - Study
A transdisciplinary team acting on evidence through analyses of moot malpractice cases.
Citation Text:
Constantino RE. A transdisciplinary team acting on evidence through analyses of moot malpractice cases. Dimens Crit Care Nurs. 2007;26(4):150-5.
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psnet.ahrq.gov/issue/mock-trial-2009-rsna-annual-meeting-jury-exonerates-radiologist-failure-communicate-abnormal
October 23, 2018 - Commentary
Mock trial at 2009 RSNA annual meeting: jury exonerates radiologist for failure to communicate abnormal finding—but...
Citation Text:
Berlin L. Mock trial at 2009 RSNA annual meeting: Jury exonerates radiologist for failure to communicate abnormal finding--but.. Radiology. 20…
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psnet.ahrq.gov/issue/applying-toyota-production-system-using-patient-safety-alert-system-reduce-error
June 21, 2015 - Commentary
Applying the Toyota Production System: using a patient safety alert system to reduce error.
Citation Text:
Furman C, Caplan RA. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007;33(7):376-386.
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psnet.ahrq.gov/issue/2007-guide-state-adverse-event-reporting-systems
November 29, 2009 - Book/Report
2007 Guide to State Adverse Event Reporting Systems.
Citation Text:
2007 Guide to State Adverse Event Reporting Systems. Rosenthal J, Takach M. Portland, ME: National Academy for State Health Policy; December 2007. Publication No. 2007-301.
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psnet.ahrq.gov/issue/verbal-medication-orders-or
March 06, 2024 - Commentary
Verbal medication orders in the OR.
Citation Text:
Hendrickson T. Verbal medication orders in the OR. AORN J. 2007;86(4):626-9.
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psnet.ahrq.gov/issue/imagining-future-diagnostic-performance-feedback
September 01, 2021 - Commentary
Imagining the future of diagnostic performance feedback.
Citation Text:
Rosner BI, Zwaan L, Olson APJ. Imagining the future of diagnostic performance feedback. Diagnosis (Berl). 2023;10(1):31-37. doi:10.1515/dx-2022-0055.
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psnet.ahrq.gov/issue/patient-concerns-about-medical-errors-emergency-departments
March 21, 2017 - Study
Patient concerns about medical errors in emergency departments.
Citation Text:
Burroughs TE, Waterman AD, Gallagher TH, et al. Patient concerns about medical errors in emergency departments. Acad Emerg Med. 2005;12(1):57-64.
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psnet.ahrq.gov/issue/diagnostic-excellence-through-lens-patient-centeredness
June 24, 2020 - Commentary
Diagnostic excellence through the lens of patient-centeredness.
Citation Text:
Berwick DM. Diagnostic Excellence Through the Lens of Patient-Centeredness. JAMA. 2021;326(21):2127-2128. doi:10.1001/jama.2021.19513.
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psnet.ahrq.gov/issue/health-care-governance-quality-and-safety-new-agenda
August 09, 2023 - Review
Health care governance for quality and safety: the new agenda.
Citation Text:
Clough J, Nash DB. Health care governance for quality and safety: the new agenda. Am J Med Qual. 2007;22(3):203-13.
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psnet.ahrq.gov/issue/special-k-no-license-kill-accidental-ketamine-overdose-induction-general-anesthesia
March 17, 2021 - Commentary
Special K with no license to kill: accidental ketamine overdose on induction of general anesthesia.
Citation Text:
Warner LL, Smischney N. Accidental Ketamine Overdose on Induction of General Anesthesia. Am J Case Rep. 2018;19:10-12.
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psnet.ahrq.gov/issue/taking-aim-infusion-confusion
June 06, 2018 - Commentary
Taking aim at infusion confusion.
Citation Text:
Burdeu G, Crawford R, Van de Vreede M, et al. Taking aim at infusion confusion. J Nurs Care Qual. 2006;21(2):151-159.
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pso.ahrq.gov/resources/educational-tools
August 01, 2022 - SHARE:
More topics in this section
Resources
Resources
Resources About the Patient Safety and Quality Improvement Act of 2005
Patient Safety Act
Patient Safety Rule
HHS Guidance
Guides
Other Educational Materials
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psnet.ahrq.gov/issue/addressing-burnout-behavioral-health-workforce-through-organizational-strategies
December 24, 2008 - Book/Report
Addressing Burnout in the Behavioral Health Workforce through Organizational Strategies.
Citation Text:
Addressing Burnout in the Behavioral Health Workforce through Organizational Strategies. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2022.&nbs…
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www.ahrq.gov/news/newsroom/case-studies/202504.html
June 01, 2025 - Harborview Medical Center Uses AHRQ’s Quality Indicators To Improve Patient Safety
Search All Impact Case Studies
June 2025
Harborview Medical Center in Seattle, Washington, has improved patient safety across its facilities using AHRQ’s Quality Indicators (QIs) — standardized measures used to assess and m…
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digital.ahrq.gov/sites/default/files/docs/page/THQITStoriesMcConnochie2010.pdf
January 01, 2001 - Integrated Telemedicine System Demonstrates Reduction in Children’s Emergency Department Visits
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digital.ahrq.gov/organization/university-wisconsin-madison
January 01, 2023 - University of Wisconsin - Madison
Bedside Notes: A Multicenter Trial to Improve Family Clinical Note Access and Outcomes for Hospitalized Children
Description
This research will evaluate the effectiveness of Bedside Notes, a digital health solution designed to provide caregive…
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digital.ahrq.gov/location/usa-wi-madison
January 01, 2023 - USA, WI, Madison
Bedside Notes: A Multicenter Trial to Improve Family Clinical Note Access and Outcomes for Hospitalized Children
Description
This research will evaluate the effectiveness of Bedside Notes, a digital health solution designed to provide caregivers with real-time…
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psnet.ahrq.gov/issue/handbook-perioperative-and-procedural-patient-safety
December 01, 2021 - Book/Report
Handbook of Perioperative and Procedural Patient Safety.
Citation Text:
Handbook of Perioperative and Procedural Patient Safety. Sanchez JA, Higgins RSD, Kent PS, eds. St Louis, MO: Elsevier; 2024. ISBN: 9780323661799.
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