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www.ahrq.gov/hai/clabsi-tools/appendix-4.html
March 01, 2018 - Appendix 4: Central Line Cart Inventory
Tools for Reducing Central Line-Associated Blood Stream Infections
These tools will help your unit implement evidence-based practices and eliminate central line-associated blood stream infections (CLABSI). When used with the CUSP (Comprehensive Unit-based Safety Program…
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www.ahrq.gov/topics/pressure-ulcers.html
Pressure Ulcers
Each year, more than 2.5 million people in the United States develop pressure ulcers. These skin lesions bring pain, associated risk for serious infection, and increased health care utilization. Pressure ulcers are associated with longer hospital stays and increased morbidity and m…
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digital.ahrq.gov/ahrq-funded-projects/past-initiatives/privacy-and-security-project/utah
January 01, 2023 - Utah
Team Description
The Utah Department of Health (UDOH) has subcontracted with RTI International to address privacy and security issues affecting the exchange of electronic health information. Known as eHealth, the secure sharing of health information electronically is safer for patient…
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digital.ahrq.gov/organization/university-north-carolina-chapel-hill
January 01, 2023 - University of North Carolina Chapel Hill
Development and Assessment of Artificial Intelligence (AI)-Enhanced Pretreatment Peer-review Process to Improve Patient Safety in Radiation Oncology
Description
This research develops and evaluates an artificial intelligence-enhanced pr…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/lean
January 01, 2023 - Lean
Also Known As
Toyota Production System (TPS)
Examples
Smith M, Cunningham S. Case study: using lean principles, how Charleston area medical center ED was able to reduce wait time by 95%. 2007 Society for Health Systems Conference; 2007; New Orleans, LA; 2007.
Description
L…
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digital.ahrq.gov/location/usa-mo-st-louis
January 01, 2023 - USA, MO, St. Louis
EnhanCed HandOffs (ECHO)
Description
This research will develop and evaluate a machine learning-augmented and telemedicine-augmented sociotechnical intervention for postoperative handoffs to reduce the risks of patient complications and improve patient-cen…
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digital.ahrq.gov/2018-year-review/research-spotlights
January 01, 2018 - Research Spotlights
AHRQ Health IT Safety Investigators are Using Health IT to Make a Real Difference in Improving Patient Safety
Research on Health IT Safety Special Emphasis Notice ( NOT-HS-16-009 ):
AHRQ continues to fund research on safe health IT practices related to the design,…
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psnet.ahrq.gov/node/47524/psn-pdf
June 19, 2019 - Learning from patients' experiences related to diagnostic
errors is essential for progress in patient safety.
June 19, 2019
Giardina TD, Haskell H, Menon S, et al. Learning From Patients' Experiences Related To Diagnostic Errors
Is Essential For Progress In Patient Safety. Health Aff (Millwood). 2018;37(11):1821-18…
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psnet.ahrq.gov/node/847717/psn-pdf
April 19, 2023 - Quality improvement initiative to decrease central line-
associated bloodstream infections during the COVID-19
pandemic: a "zero harm" approach.
April 19, 2023
Redstone CS, Zadeh M, Wilson M-A, et al. Quality improvement initiative to decrease central line-
associated bloodstream infections during the COVID-19 pan…
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psnet.ahrq.gov/node/38553/psn-pdf
April 14, 2010 - The effect of computerized physician order entry on
medication prescription errors and clinical outcome in
pediatric and intensive care: a systematic review.
April 14, 2010
van Rosse F, Maat B, Rademaker CMA, et al. The effect of computerized physician order entry on
medication prescription errors and clinical out…
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psnet.ahrq.gov/node/39302/psn-pdf
February 17, 2010 - Preoperative briefing in the operating room: shared
cognition, teamwork, and patient safety.
February 17, 2010
Einav Y, Gopher D, Kara I, et al. Preoperative briefing in the operating room: shared cognition, teamwork,
and patient safety. Chest. 2010;137(2):443-9. doi:10.1378/chest.08-1732.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/39730/psn-pdf
December 21, 2014 - Surgical case listing accuracy: failure analysis at a high-
volume academic medical center.
December 21, 2014
Cima RR, Hale C, Kollengode A, et al. Surgical case listing accuracy: failure analysis at a high-volume
academic medical center. Arch Surg. 2010;145(7):641-6. doi:10.1001/archsurg.2010.112.
https://psnet.a…
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psnet.ahrq.gov/issue/vha-national-patient-safety-improvement-handbook
April 12, 2019 - Organizational Policy/Guidelines
VHA National Patient Safety Improvement Handbook.
Save
Save to your library
Print
Download PDF
Share
Facebook
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Linkedin
Copy URL
January 17, 2012
A handbook developed by the …
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psnet.ahrq.gov/node/42081/psn-pdf
April 09, 2013 - Types and origins of diagnostic errors in primary care
settings.
April 9, 2013
Singh H, Giardina TD, Meyer AND, et al. Types and origins of diagnostic errors in primary care settings.
JAMA Intern Med. 2013;173(6):418-425. doi:10.1001/jamainternmed.2013.2777.
https://psnet.ahrq.gov/issue/types-and-origins-diagnosti…
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psnet.ahrq.gov/node/43773/psn-pdf
May 01, 2015 - Efforts To Improve Patient Safety Result in 1.3 Million
Fewer Patient Harms: Interim Update on 2013 Annual
Hospital-Acquired Condition Rate and Estimates of Cost
Savings and Deaths Averted From 2010 to 2013.
May 1, 2015
Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. …
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psnet.ahrq.gov/node/44925/psn-pdf
July 27, 2018 - Improving safety for hospitalized patients: much progress
but many challenges remain.
July 27, 2018
Kronick R, Arnold S, Brady J. Improving Safety for Hospitalized Patients: Much Progress but Many
Challenges Remain. JAMA. 2016;316(5):489-90. doi:10.1001/jama.2016.7887.
https://psnet.ahrq.gov/issue/improving-safety…
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psnet.ahrq.gov/node/46135/psn-pdf
July 11, 2017 - Two-state collaborative study of a multifaceted
intervention to decrease ventilator-associated events.
July 11, 2017
Rawat N, Yang T, Ali KJ, et al. Two-State Collaborative Study of a Multifaceted Intervention to Decrease
Ventilator-Associated Events. Crit Care Med. 2017;45(7):1208-1215.
doi:10.1097/CCM.0000000000…
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psnet.ahrq.gov/node/44034/psn-pdf
January 19, 2016 - Surgical checklist implementation project: the impact of
variable WHO checklist compliance on risk-adjusted
clinical outcomes after national implementation: a
longitudinal study.
January 19, 2016
Mayer EK, Sevdalis N, Rout S, et al. Surgical Checklist Implementation Project: The Impact of Variable
WHO Checklist C…
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psnet.ahrq.gov/node/45319/psn-pdf
September 01, 2018 - Special Issue: Progress at the Intersection of Patient
Safety and Medical Liability.
September 1, 2018
Ridgely MS, Greenberg MD, Clancy CM, eds. Health Serv Res. 2016;51(suppl 3):2395-2648.
https://psnet.ahrq.gov/issue/special-issue-progress-intersection-patient-safety-and-medical-liability
Medical liability refor…
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psnet.ahrq.gov/node/46612/psn-pdf
February 22, 2018 - Influencing organisational culture to improve hospital
performance in care of patients with acute myocardial
infarction: a mixed-methods intervention study.
February 22, 2018
Curry LA, Brault MA, Linnander EL, et al. Influencing organisational culture to improve hospital
performance in care of patients with acute …