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psnet.ahrq.gov/issue/hospital-discharge-documentation-and-risk-rehospitalisation
March 25, 2015 - Study
Hospital discharge documentation and risk of rehospitalisation.
Citation Text:
Hansen LO, Strater A, Smith L, et al. Hospital discharge documentation and risk of rehospitalisation. BMJ Qual Saf. 2011;20(9):773-8. doi:10.1136/bmjqs.2010.048470.
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psnet.ahrq.gov/issue/use-simulation-based-education-reduce-catheter-related-bloodstream-infections
June 27, 2018 - Study
Use of simulation-based education to reduce catheter-related bloodstream infections.
Citation Text:
Barsuk JH, Cohen ER, Feinglass J, et al. Use of simulation-based education to reduce catheter-related bloodstream infections. Arch Intern Med. 2009;169(15):1420-3. doi:10.1001/archin…
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psnet.ahrq.gov/issue/second-victim-phenomenon-after-clinical-error-design-and-evaluation-website-reduce-caregivers
October 11, 2017 - Study
The second victim phenomenon after a clinical error: the design and evaluation of a website to reduce caregivers' emotional responses after a clinical error.
Citation Text:
Mira JJ, Carrillo I, Guilabert M, et al. The Second Victim Phenomenon After a Clinical Error: The Design and …
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psnet.ahrq.gov/issue/improving-patient-safety-and-optimizing-nursing-teamwork-using-crew-resource-management
March 13, 2013 - Study
Improving patient safety and optimizing nursing teamwork using crew resource management techniques.
Citation Text:
West P, Sculli GL, Fore AM, et al. Improving patient safety and optimizing nursing teamwork using crew resource management techniques. J Nurs Adm. 2012;42(1):15-20. do…
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psnet.ahrq.gov/issue/reducing-risk-and-promoting-patient-safety-nih-intramural-clinical-research-draft-report
November 18, 2020 - Book/Report
Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report.
Citation Text:
Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report. The Clinical Center Working Group Report to the Advisory Committee to the…
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psnet.ahrq.gov/issue/optimizing-smart-pump-technology-increasing-critical-safety-alerts-and-reducing-clinically
February 12, 2014 - Study
Optimizing smart pump technology by increasing critical safety alerts and reducing clinically insignificant alerts.
Citation Text:
Mansfield J, Jarrett S. Optimizing smart pump technology by increasing critical safety alerts and reducing clinically insignificant alerts. Hosp Pharm.…
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psnet.ahrq.gov/issue/henry-ford-health-system-no-harm-campaign-comprehensive-model-reduce-harm-and-save-lives
May 11, 2019 - Commentary
The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives.
Citation Text:
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 mo…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module_4-speaker-notes.docx
September 01, 2015 - AHRQ Safety Program for Reducing CAUTI in Hospitals
Preventing CAUTI in the ICU Setting
Module 4: Summary and Next Steps
SAY:
SLIDE 1
SAY:
You’ve now seen three modules on how to stop catheter-associated urinary tract infections, or CAUTI, in your intensive care unit, or ICU. In Module 1, you learned that hos…
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psnet.ahrq.gov/issue/impact-intervention-reduce-prescribing-errors-pediatric-intensive-care-unit
March 09, 2022 - Study
Impact of an intervention to reduce prescribing errors in a pediatric intensive care unit.
Citation Text:
Martinez-Anton A, Sanchez I, Casanueva L. Impact of an intervention to reduce prescribing errors in a pediatric intensive care unit. Intensive Care Med. 2012;38(9):1532-8. do…
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psnet.ahrq.gov/issue/reducing-retained-foreign-objects-operating-room-quality-improvement-initiative
April 19, 2023 - Study
Reducing retained foreign objects in the operating room: a quality improvement initiative.
Citation Text:
Keane OA, Chambers C, Brady CM, et al. Reducing retained foreign objects in the operating room: a quality improvement initiative. J Am Coll Surg. 2023;237(6):864-872. doi:10.10…
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psnet.ahrq.gov/issue/paradoxical-effects-hospital-based-multi-intervention-programme-aimed-reducing-medication
September 13, 2023 - Study
Paradoxical effects of a hospital-based, multi-intervention programme aimed at reducing medication round interruptions.
Citation Text:
Tomietto M, Sartor A, Mazzocoli E, et al. Paradoxical effects of a hospital-based, multi-intervention programme aimed at reducing medication round …
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psnet.ahrq.gov/issue/patient-misidentification-papanicolaou-tests-systems-based-approach-reducing-errors
December 26, 2014 - Study
Patient misidentification in Papanicolaou tests: a systems-based approach to reducing errors.
Citation Text:
Meyer E, Underwood S, Padmanabhan V. Patient misidentification in Papanicolaou tests: a systems-based approach to reducing errors. Arch Pathol Lab Med. 2009;133(8):1297-30…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use
Learning From Antibiotic-Associated Adverse Events
An antibiotic-associated adverse event is any event or situation that you would not want to happen again because it either caused your patient harm or had the potential to cause harm. The purpose of this tool is to provi…
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psnet.ahrq.gov/issue/emergency-medical-services-system-changes-reduce-pediatric-epinephrine-dosing-errors
October 06, 2021 - Study
Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting.
Citation Text:
Kaji AH, Gausche-Hill M, Conrad H, et al. Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital settin…
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psnet.ahrq.gov/node/47246/psn-pdf
September 19, 2018 - Implementing Optimal Team-Based Care to Reduce
Clinician Burnout.
September 19, 2018
Smith CD, Corbridge S, Dopp AL, et al. NAM Perspectives. Washington DC: National Academy of
Medicine; 2018.
https://psnet.ahrq.gov/issue/implementing-optimal-team-based-care-reduce-clinician-burnout
Teamwork can contribute to a h…
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psnet.ahrq.gov/node/46764/psn-pdf
March 28, 2018 - The Report of the Short Life Working Group on Reducing
Medication-related Harm.
March 28, 2018
Department of Health and Social Care. London, England: Crown Publishing; February 2018.
https://psnet.ahrq.gov/issue/report-short-life-working-group-reducing-medication-related-harm
Medication errors are a prominent chal…
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psnet.ahrq.gov/node/43355/psn-pdf
July 23, 2014 - Nearing zero...reducing grade C medication errors.
July 23, 2014
Cockerham J, Figueroa-Altmann A, Foxen C, et al. Nearing zero..reducing grade C medication errors. Nurs
Manage. 2014;45(7):26-31. doi:10.1097/01.NUMA.0000451033.38845.d3.
https://psnet.ahrq.gov/issue/nearing-zeroreducing-grade-c-medication-errors
Thi…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/defects.html
May 01, 2017 - Learn From Defects - Implementation Guide
Purpose: To identify the types of systems that contributed to the defect (an event or situation that you do not want to happen again) and to plan the followup steps needed to improve safety.
Who should use this tool? Senior leaders, facility team leads, …
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digital.ahrq.gov/ahrq-funded-projects/enabling-shared-decision-making-reduce-harm-drug-interactions-end-end/final-report
January 01, 2023 - Enabling Shared Decision Making to Reduce Harm from Drug Interactions: An End-to-End Demonstration - Final Report
Citation
Malone D. Enabling Shared Decision Making to Reduce Harm from Drug Interactions: An End-to-End Demonstration - Final Report. (Prepared by the University of Utah under Grant No. U1…
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digital.ahrq.gov/ahrq-funded-projects/integrating-contextual-factors-clinical-decision-support-reduce-contextual/final-report
January 01, 2023 - Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error and Improve Outcomes in Ambulatory Care - Final Report
Citation
Weiner S. Integrating Contextual Factors into Clinical Decision Support to Reduce Contextual Error and Improve Outcomes in Ambulatory Care - Final Re…