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psnet.ahrq.gov/node/867700/psn-pdf
March 01, 2023 - Toolkit for Reducing Central Line-Associated Blood
Stream Infections.
March 1, 2023
Agency for Healthcare Research and Quality. Toolkit for Reducing Central Line-Associated Blood Stream
Infections. March 2023.
https://psnet.ahrq.gov/issue/toolkit-reducing-central-line-associated-blood-stream-infections
Eliminatin…
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psnet.ahrq.gov/node/39318/psn-pdf
June 02, 2010 - Approaches to reducing the most important patient errors
in primary health-care: patient and professional
perspectives.
June 2, 2010
Buetow S, Kiata L, Liew T, et al. Approaches to reducing the most important patient errors in primary
health-care: patient and professional perspectives. Health Soc Care Community. 2…
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psnet.ahrq.gov/node/72829/psn-pdf
March 10, 2021 - Safe Practices to Reduce CPOE Alert Fatigue through
Monitoring, Analysis, and Optimization.
March 10, 2021
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.
https://psnet.ahrq.gov/issue/safe-practices-reduce-cpoe-alert-fatigue-through-monitoring-analysis-and-
optimization
Alert…
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psnet.ahrq.gov/node/44985/psn-pdf
January 01, 2020 - Human factors and quality improvement in the emergency
department: reducing potential errors in blood collection.
March 30, 2016
Bashkin O, Caspi S, Swissa A, et al. Human Factors and Quality Improvement in the Emergency
Department: Reducing Potential Errors in Blood Collection. J Patient Saf. 2020;16(1):47-51.
do…
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psnet.ahrq.gov/node/41509/psn-pdf
January 03, 2017 - The Henry Ford Health System No Harm Campaign: a
comprehensive model to reduce harm and save lives.
January 3, 2017
Conway WA, Hawkins S, Jordan J, et al. 2011 John M. Eisenberg Patient Safety and Quality Awards. The
Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives.
in…
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psnet.ahrq.gov/node/838030/psn-pdf
September 07, 2022 - Rethinking use of air-safety principles to reduce fatal
hospital errors.
September 7, 2022
Rethinking use of air-safety principles to reduce fatal hospital errors.
doi:10.1377/forefront.20220824.965364.
https://psnet.ahrq.gov/issue/rethinking-use-air-safety-principles-reduce-fatal-hospital-errors
The safety of co…
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psnet.ahrq.gov/node/46666/psn-pdf
March 28, 2018 - Effectiveness of a clinical knowledge support system for
reducing diagnostic errors in outpatient care in Japan: a
retrospective study.
March 28, 2018
Shimizu T, Nemoto T, Tokuda Y. Effectiveness of a clinical knowledge support system for reducing
diagnostic errors in outpatient care in Japan: A retrospective stud…
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psnet.ahrq.gov/node/45620/psn-pdf
December 07, 2016 - A systematic review of the unintended consequences of
clinical interventions to reduce adverse outcomes.
December 7, 2016
Manojlovich M, Lee S, Lauseng D. A Systematic Review of the Unintended Consequences of Clinical
Interventions to Reduce Adverse Outcomes. J Patient Saf. 2016;12(4):173-179.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/42681/psn-pdf
December 13, 2013 - Medication reconciliation: reducing risk for medication
misadventure during transition from hospital to assisted
living.
December 13, 2013
Fitzgibbon M, Lorenz R, Lach H. Medication reconciliation: reducing risk for medication misadventure
during transition from hospital to assisted living. J Gerontol Nurs. 2013;3…
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psnet.ahrq.gov/node/42329/psn-pdf
December 18, 2014 - Health care failure mode and effect analysis to reduce
NICU line–associated bloodstream infections.
December 18, 2014
Chandonnet CJ, Kahlon PS, Rachh P, et al. Health care failure mode and effect analysis to reduce NICU
line-associated bloodstream infections. Pediatrics. 2013;131(6):e1961-9. doi:10.1542/peds.2012-3…
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psnet.ahrq.gov/node/35182/psn-pdf
April 11, 2011 - Standard drug concentrations and smart-pump
technology reduce continuous-medication-infusion errors
in pediatric patients.
April 11, 2011
Larsen G, Parker HB, Cash J, et al. Standard drug concentrations and smart-pump technology reduce
continuous-medication-infusion errors in pediatric patients. Pediatrics. 2005;1…
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psnet.ahrq.gov/node/47728/psn-pdf
February 20, 2019 - Implementation of bar-code medication administration to
reduce patient harm.
February 20, 2019
Thompson KM, Swanson KM, Cox DL, et al. Implementation of Bar-Code Medication Administration to
Reduce Patient Harm. Mayo Clin Proc Innov Qual Outcomes. 2018;2(4):342-351.
doi:10.1016/j.mayocpiqo.2018.09.001.
https://ps…
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psnet.ahrq.gov/node/46128/psn-pdf
June 14, 2017 - Does a checklist reduce the number of errors made in
nurse-assembled discharge prescriptions?
June 14, 2017
Byrne C, Sierra H, Tolhurst R. Does a checklist reduce the number of errors made in nurse-assembled
discharge prescriptions? Br J Nurs. 2017;26(8):464-467. doi:10.12968/bjon.2017.26.8.464.
https://psnet.ahrq…
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psnet.ahrq.gov/node/73158/psn-pdf
April 21, 2021 - Better understanding the downsides of low value
healthcare could reduce harm.
April 21, 2021
Brownlee SM, Korenstein D. Better understanding the downsides of low value healthcare could reduce
harm. BMJ. 2021;372:n117. doi:10.1136/bmj.n117.
https://psnet.ahrq.gov/issue/better-understanding-downsides-low-value-healt…
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psnet.ahrq.gov/node/47872/psn-pdf
March 27, 2019 - Overview of the Environmental Scan of Primary Care-
Based Effort To Reduce Readmissions.
March 27, 2019
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality;
March 2019. AHRQ Publication No. 18(19)-0055-EF.
https://psnet.ahrq.gov/issue/overview-environmental-scan-primar…
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psnet.ahrq.gov/node/74176/psn-pdf
December 15, 2021 - Reducing medication errors for adults in hospital
settings.
December 15, 2021
Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Reducing medication errors for adults in hospital settings.
Cochrane Database Syst Rev. 2021;11(11):CD009985. doi:10.1002/14651858.cd009985.pub2.
https://psnet.ahrq.gov/issue/reducing-medi…
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www.ahrq.gov/hai/cusp/summary/index.html
September 01, 2017 - Comprehensive Unit-based Safety Program: Accelerating the Adoption of Evidence-Based Practices To Prevent Healthcare-Associated Infections
Project Summary
The Comprehensive Unit-based Safety Program (CUSP) is a proven method for preventing healthcare-associated infections (HAIs) and other patient harms. CUSP…
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www.ahrq.gov/news/newsroom/case-studies/201808.html
December 01, 2018 - Tampa Hospital Uses AHRQ Tools to Reduce Emergency Department CAUTI Rates by 75 Percent
Search All Impact Case Studies
December 2018
Tampa General Hospital staff participated in an AHRQ project and implemented several elements from AHRQ’s Comprehensive Unit-based Safety Program (CUSP) to reduce healthcare…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
December 01, 2017 - Example: You get the supply from another area or you manage without it
Second-Order
Problem Solving
Reduces
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psnet.ahrq.gov/node/43629/psn-pdf
May 01, 2015 - Exposing physicians to reduced residency work hours
did not adversely affect patient outcomes after residency.
May 1, 2015
Jena AB, Schoemaker L, Bhattacharya J. Exposing physicians to reduced residency work hours did not
adversely affect patient outcomes after residency. Health Aff (Millwood). 2014;33(10):1832-40.…