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psnet.ahrq.gov/node/41955/psn-pdf
January 09, 2013 - Making Medical Devices Safer at Home.
January 9, 2013
Consumer Updates. Silver Spring, MD: US Food and Drug Administration; December 12, 2012.
https://psnet.ahrq.gov/issue/making-medical-devices-safer-home
Highlighting concerns associated with patients' use of medical devices at home, such as difficulty
understand…
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psnet.ahrq.gov/node/42830/psn-pdf
December 18, 2013 - How to Identify and Address Unsafe Conditions
Associated With Health IT.
December 18, 2013
Wallace C, Zimmer KP, Possanza L, Giannini R, Solomon R. Washington, DC: Office of the National
Coordinator for Health Information Technology; November 15, 2013.
https://psnet.ahrq.gov/issue/how-identify-and-address-unsafe-c…
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psnet.ahrq.gov/node/40668/psn-pdf
March 04, 2015 - Body CT: technical advances for improving safety.
March 4, 2015
Marin D, Nelson RC, Rubin GD, et al. Body CT: technical advances for improving safety. AJR Am J
Roentgenol. 2011;197(1):33-41. doi:10.2214/AJR.11.6755.
https://psnet.ahrq.gov/issue/body-ct-technical-advances-improving-safety
This article explores risk…
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psnet.ahrq.gov/node/42332/psn-pdf
June 12, 2013 - Quality improvement through implementation of
discharge order reconciliation.
June 12, 2013
Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order
reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050.
https://psnet.ahrq.gov/issue/quality-impr…
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psnet.ahrq.gov/node/40568/psn-pdf
June 29, 2011 - Tubing misconnections: normalization of deviance.
June 29, 2011
Simmons D, Symes L, Guenter P, et al. Tubing misconnections: normalization of deviance. Nutr Clin Pract.
2011;26(3):286-293. doi:10.1177/0884533611406134.
https://psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance
Analyzing published ca…
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psnet.ahrq.gov/node/41411/psn-pdf
October 19, 2012 - Minnesota Hospital Association Statewide Project: SAFE
from FALLS.
October 19, 2012
Apold J, Quigley PA. Minnesota Hospital Association Statewide Project: SAFE from FALLS. J Nurs Care
Qual. 2012;27(4):299-306. doi:10.1097/NCQ.0b013e3182599d1b.
https://psnet.ahrq.gov/issue/minnesota-hospital-association-statewide-p…
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psnet.ahrq.gov/node/35382/psn-pdf
October 05, 2005 - Rx for a better prescription. Hospital bans doctors from
using confusing medical abbreviations.
October 5, 2005
Hall J. Fredericksburg Times. September 25, 2005
https://psnet.ahrq.gov/issue/rx-better-prescription-hospital-bans-doctors-using-confusing-medical-
abbreviations
This article presents one hospital’s pro…
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psnet.ahrq.gov/node/42493/psn-pdf
August 14, 2013 - Partnering to prevent falls: using a multimodal
multidisciplinary team.
August 14, 2013
Volz TM, Swaim J. Partnering to prevent falls: using a multimodal multidisciplinary team. J Nurs Adm.
2013;43(6):336-41. doi:10.1097/NNA.0b013e3182942c5a.
https://psnet.ahrq.gov/issue/partnering-prevent-falls-using-multimodal-m…
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digital.ahrq.gov/organization/mainegeneral-medical-center
January 01, 2023 - Mainegeneral Medical Center
Improving Health Information Technology Implementation in a Rural Health System - 2008
Principal Investigator
Mingle, Daniel
Project Name
Improving Health Information Technology Implementation in a Rural Health System
…
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psnet.ahrq.gov/node/43055/psn-pdf
May 01, 2017 - AHRQ's Safety Program for Ambulatory Surgery.
May 1, 2017
Health Research & Educational Trust. Rockville, MD: Agency for Healthcare Research and Quality; May
2017. AHRQ Publication No. 16(17)-0019-1-EF.
https://psnet.ahrq.gov/issue/ahrqs-safety-program-ambulatory-surgery
This report provides information about a na…
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digital.ahrq.gov/ahrq-funded-projects/integrating-contextual-factors-clinical-decision-support-reduce-contextual/citation/contextualizing
January 01, 2023 - Contextualizing care: An essential and measurable clinical competency.
Citation
Weiner SJ. Contextualizing care: An essential and measurable clinical competency. Patient Educ Couns. 2022 Mar;105(3):594-598. doi: 10.1016/j.pec.2021.06.016. Epub 2021 Jun 15. PMID: 34158194.
Link
https://pubmed.n…
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psnet.ahrq.gov/node/47556/psn-pdf
November 28, 2018 - Improving Diagnosis.
November 28, 2018
Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70.
https://psnet.ahrq.gov/issue/improving-diagnosis
This special issue raises awareness of challenges to reducing diagnostic error. Articles discuss insights
from experts about how to improve diagnosis, t…
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psnet.ahrq.gov/node/43491/psn-pdf
January 01, 2015 - The systems approach to medicine: controversy and
misconceptions.
December 9, 2014
Dekker SWA, Leveson NG. The systems approach to medicine: controversy and misconceptions. BMJ
Qual Saf. 2015;24(1):7-9. doi:10.1136/bmjqs-2014-003106.
https://psnet.ahrq.gov/issue/systems-approach-medicine-controversy-and-misconcept…
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psnet.ahrq.gov/node/42364/psn-pdf
September 18, 2013 - The pursuit of better diagnostic performance: a human
factors perspective.
September 18, 2013
Henriksen K, Brady J. The pursuit of better diagnostic performance: a human factors perspective. BMJ
Qual Saf. 2013;22(Suppl 2):ii1-ii5. doi:10.1136/bmjqs-2013-001827.
https://psnet.ahrq.gov/issue/pursuit-better-diagnosti…
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psnet.ahrq.gov/node/38341/psn-pdf
April 02, 2009 - CPOE: it don't come easy.
April 2, 2009
Anderson HJ. CPOE: it don't come easy. Health Data Manag. 2009;17(1):18-20, 22, 24 passim.
https://psnet.ahrq.gov/issue/cpoe-it-dont-come-easy
Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE)
systems could reduce medical errors…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/qi-action-notes.docx
April 01, 2022 - Quality Improvement in Action Facilitator Guide
CUSP Module: Quality Improvement in Action
Facilitator Guide
Slide Number and Image
This module, titled “Quality Improvement in Action,” is part of the Agency for Healthcare Research and Quality, or AHRQ, Safety Program for Intensive Care Units: Preventing Central…
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www.ahrq.gov/sites/default/files/2025-03/singh2-report.pdf
January 01, 2025 - Final Progress Report: Diagnostic Error in Medicine Annual Conference
AHRQ Grant Final Progress Report
Title of Project: Diagnostic Error in Medicine Annual Conference
Principal Investigator: Hardeep Singh, MD
Team Members:
• Paul L. Epner, M.Ed, MBA, Executive Vice President, Society to Improve Diagnosis in Me…
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www.ahrq.gov/sites/default/files/2024-01/lannon1-report.pdf
January 01, 2024 - Final Progress Report: Pursuing Perfection in Pediatric Therapeutics
FINAL PROGRESS REPORT
Title of Project:
Pursuing Perfection in Pediatric Therapeutics
Principal Investigator:
Carole Lannon, MD, MPH
Team Members:
Research Director: Michael Seid, PhD
Education Liaison: Peter Margolis, MD, PhD
Program Manage…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/guide-appcusp.pdf
December 01, 2017 - Applying CUSP To Promote Safe Surgery
AHRQ Safety Program for Surgery
Applying the Comprehensive
Unit-based Safety Program
(CUSP) To Promote Safe
Surgery
AHRQ Publication No. 16(18)-0004-14-EF
December 2017
AHRQ Safety Program for Surgery
Contents
Introduction .........................................…
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - SPOTLIGHT CASE
Some Patients Can't Wait: Improving Timeliness of Emergency Department Care
Citation Text:
Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…