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psnet.ahrq.gov/node/35953/psn-pdf
May 24, 2006 - Too exhausted to act safely?
May 24, 2006
Spath P. Hosp Peer Rev. 2006;31(4):56-59.
https://psnet.ahrq.gov/issue/too-exhausted-act-safely
The author discusses how to identify and evaluate worker fatigue. Part II of this article outlines specific
techniques for reducing health care worker fatigue.
https://psnet.ah…
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psnet.ahrq.gov/node/36259/psn-pdf
October 21, 2010 - How we cut drug errors.
October 21, 2010
Nicol N, Huminski L. How we cut drug errors. At one hospital, IT and changed culture saves lives. Modern
healthcare. 2006;36(34):38.
https://psnet.ahrq.gov/issue/how-we-cut-drug-errors
This article discusses technology-based tools and culture change strategies employed by o…
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psnet.ahrq.gov/node/39871/psn-pdf
September 22, 2010 - Kaiser Permanente's innovation on the front lines.
September 22, 2010
McCreary L. Kaiser Permanente's innovation on the front lines. Harv Bus Rev. 2010;88(9):92, 94-7, 126.
https://psnet.ahrq.gov/issue/kaiser-permanentes-innovation-front-lines
This article describes how innovation has reduced medication errors and …
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psnet.ahrq.gov/node/39776/psn-pdf
January 25, 2017 - First, protect the patient from harm: applying adult
learning principles to patient safety.
January 25, 2017
Duffy B.
https://psnet.ahrq.gov/issue/first-protect-patient-harm-applying-adult-learning-principles-patient-safety
This piece describes how education can reduce patient harm by promoting attitude and behavi…
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digital.ahrq.gov/ahrq-funded-projects/virtual-patient-advocate-reduce-ambulatory-adverse-drug-events/publication
January 01, 2023 - State Will Stop Paying For Some Hospital Re-Admissions
Citation
Bebinger M. State Will Stop Paying For Some Hospital Re-Admissions. Available at 90.9 WBUR. Feb 8, 2011. Accessed at http://www.wbur.org/2011/02/08/readmissions
Link
http://www.wbur.org/2011/02/08/readmissions
Project Name…
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psnet.ahrq.gov/node/41329/psn-pdf
September 24, 2016 - The science of interruption.
September 24, 2016
Coiera E. The science of interruption. BMJ Qual Saf. 2012;21(5):357-60. doi:10.1136/bmjqs-2012-000783.
https://psnet.ahrq.gov/issue/science-interruption
This commentary discusses interruption research in health care, challenges to understanding its impact,
and approa…
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psnet.ahrq.gov/node/39544/psn-pdf
May 19, 2010 - Preventing infections: how Portland hospitals compare.
May 19, 2010
Rojas-Burke J. The Oregonian. May 8, 2010.
https://psnet.ahrq.gov/issue/preventing-infections-how-portland-hospitals-compare
This newspaper article describes how lessons from the Keystone ICU Project have reduced central line
infections in Oregon …
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psnet.ahrq.gov/node/37009/psn-pdf
March 18, 2010 - Doing the "right" things to correct wrong-site surgery.
March 18, 2010
Patient Safety Advisory
https://psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results
of other studies, and provides suggesti…
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psnet.ahrq.gov/node/36824/psn-pdf
October 03, 2017 - Department of Defense (DoD) Patient Safety Program.
October 3, 2017
US Department of Defense; DOD
https://psnet.ahrq.gov/issue/department-defense-dod-patient-safety-program
This Web site includes information on several initiatives within the US Military Health System to support its
culture of safety and reduce med…
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psnet.ahrq.gov/node/37904/psn-pdf
July 09, 2008 - Evidence shows cost and patient safety benefits of
emergency pharmacists.
July 9, 2008
Clancy CM.
https://psnet.ahrq.gov/issue/evidence-shows-cost-and-patient-safety-benefits-emergency-pharmacists
This article discusses activities related to reducing adverse drug events in emergency departments (EDs)
and highligh…
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psnet.ahrq.gov/node/36423/psn-pdf
December 22, 2010 - Care transitions: a threat and an opportunity for patient
safety.
December 22, 2010
Clancy CM. Care Transitions: A Threat and an Opportunity for Patient Safety. American Journal of Medical
Quality. 2006;21(6). doi:10.1177/1062860606293537.
https://psnet.ahrq.gov/issue/care-transitions-threat-and-opportunity-patien…
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psnet.ahrq.gov/node/37935/psn-pdf
February 17, 2011 - The (slowly) vanishing prescription pad.
February 17, 2011
Steinbrook R. The (slowly) vanishing prescription pad. N Engl J Med. 2008;359(2):115-7.
doi:10.1056/NEJMp0802864.
https://psnet.ahrq.gov/issue/slowly-vanishing-prescription-pad
This perspective discusses the proliferation of electronic vs. paper-based pres…
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psnet.ahrq.gov/node/35161/psn-pdf
March 13, 2016 - The forgotten tourniquet—an update.
March 13, 2016
PA Patient Saf Advis. 2016;13(1):4. http://patientsafety.pa.gov/ADVISORIES/Pages/201603_32.aspx.
https://psnet.ahrq.gov/issue/forgotten-tourniquet-update
This advisory from the Pennsylvania Patient Safety Reporting System discusses 1079 reports of
tourniquets bein…
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www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
January 01, 2024 - This reduces the risk of
dispensing a prescription to the wrong patient from 0.052 to 0.010 per 1,000
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www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary-screening-for-breast-cancer/breast-cancer-screening-january-2016
January 11, 2016 - Share to Facebook
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Share to WhatsApp
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Print
archived
Evidence Summary: Screening for Breast Cancer
Breast Cancer: Screening
January 11, 2016
Recommendations made by the USPSTF are independent of the U.S. government. …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Ludwick.pdf
June 21, 2004 - Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events
483
Surgical Safety: Addressing the
JCAHO Goals for Reducing Wrong-site,
Wrong-patient, Wrong-procedure Events
Sandra Ludwick
Abstract
Under standards set forth by the Joint Commission on Accreditatio…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/aspire_webinar2/aspire_webinar2.pptx
January 01, 2015 - Designing & Delivering Whole-Person Transitional Care The Hospital Guide to Reducing Medicaid Readmission Webinar 2
Designing & Delivering Whole-Person Transitional Care
The Hospital Guide to Reducing Medicaid Readmissions
Webinar 2: Analyze Data and Patient/Caregiver Perspectives
(Section 1 of the Guide)
Agenda
…
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www.ahrq.gov/funding/grantee-profiles/grtprofile-mcginn.html
January 01, 2024 - Grantee Profile
Integrating Clinical Prediction Rules into EHRs to Improve Care, Reduce Waste
Thomas McGinn, M.D., M.P.H.
Executive Vice President of Physician Enterprise
CommonSpirit Health
Thomas McGinn,
M.D., M.P.H.
“Very early on, AHRQ understood the language and the work.”
As a young…
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www.ahrq.gov/sites/default/files/2025-03/joo-report.pdf
January 01, 2025 - Final Progress Report: Reducing Diagnostic Error to Improve Patient Safety in COPD and Asthma (REDEFINE Study)
1. Reducing Diagnostic Error to Improve Patient Safety in COPD and Asthma
(REDEFINE Study)
Principal Investigator and Team Members/Organization:
Min J. Joo, MD, MPH, Department of Medicine, College of Medi…
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www.ahrq.gov/research/findings/final-reports/iomracereport/reldata1fig1-1.html
April 01, 2018 - Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement
Figure 1-1. A Framework for Reducing Disparities in Health Care Systems
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Table of Contents
Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement
Summary …