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psnet.ahrq.gov/node/40430/psn-pdf
October 18, 2011 - Eliminating CLABSI: A National Patient Safety Imperative.
October 18, 2011
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-
0037-1-EF.
https://psnet.ahrq.gov/issue/eliminating-clabsi-national-patient-safety-imperative
This publication reports the impact hospital p…
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digital.ahrq.gov/ahrq-funded-projects/reducing-disparities-health-care-quality-priority-populations-approach-focused/citation/asian-americans
January 01, 2023 - Improving communication between patients and providers using health information technology and other quality improvement strategies: focus on Asian Americans.
Citation
Ngo-Metzger Q, Hayes GR, Yunan Chen, et al. Improving communication between patients and providers using health information technology…
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digital.ahrq.gov/ahrq-funded-projects/reducing-disparities-health-care-quality-priority-populations-approach-focused/citation/low-income-children
January 01, 2023 - Improving communication between patients and providers using health information technology and other quality improvement strategies: focus on low-income children.
Citation
Ngo-Metzger Q, Hayes GR, Yunan Chen, et al. Improving communication between patients and providers using health information techno…
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide65.html
October 01, 2014 - 65. For the Patient Willing To Quit (Continued)
Treating Tobacco Use and Dependence: 2008 Update
Text version of slide presentation.
Strategy A4. Assist —Aid the patient in quitting (provide counseling and medication) (Continued)
Recommend the use of approved medication,
except where contra…
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psnet.ahrq.gov/node/838027/psn-pdf
September 07, 2022 - Advancing Anticoagulation Stewardship: A Playbook.
September 7, 2022
Washington DC; National Quality Forum and Anticoagulation Forum; 2022.
https://psnet.ahrq.gov/issue/advancing-anticoagulation-stewardship-playbook
Warfarin and other anticoagulants are high-alert medications that, if errors occur in their use, can…
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psnet.ahrq.gov/node/73378/psn-pdf
June 09, 2021 - Making Healthcare Safe: The Story of the Patient Safety
Movement.
June 9, 2021
Leape LL. Cham, Switzerland: Springer Nature; 2021. ISBN: 9783030711252.
https://psnet.ahrq.gov/issue/making-healthcare-safe-story-patient-safety-movement
The publication of “Error in Medicine” by Dr. Lucian Leape marked a pivotal step …
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psnet.ahrq.gov/node/37412/psn-pdf
December 12, 2007 - The checklist.
December 12, 2007
Gawande A. New Yorker. December 10, 2007:86-95.
https://psnet.ahrq.gov/issue/checklist
This article by bestselling author and surgeon Atul Gawande illustrates the complexity of intensive care and
profiles Peter Pronovost, the Johns Hopkins intensivist and safety leader whose effort…
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psnet.ahrq.gov/node/41957/psn-pdf
May 04, 2016 - Safety Considerations for Product Design to Minimize
Medication Errors: Guidance for Industry.
May 4, 2016
Rockville, MD: Center for Drug Evaluation and Research, US Food and Drug Administration; April 2016.
https://psnet.ahrq.gov/issue/safety-considerations-product-design-minimize-medication-errors-guidance-
indu…
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psnet.ahrq.gov/node/865683/psn-pdf
Our stubborn quest for diagnostic certainty.
June 1, 1989
Kassirer JP. Our stubborn quest for diagnostic certainty. N Engl J Med. 1989;320(22):1489-1491.
doi:10.1056/nejm198906013202211.
https://psnet.ahrq.gov/issue/our-stubborn-quest-diagnostic-certainty
The topic of uncertainty has been largely neglected in the …
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psnet.ahrq.gov/node/48170/psn-pdf
July 31, 2019 - Developing resilience to combat nurse burnout.
July 31, 2019
Quick Safety. July 15, 2019;(50):1-4.
https://psnet.ahrq.gov/issue/developing-resilience-combat-nurse-burnout
This newsletter article discusses nurse burnout and how to reduce conditions that contribute to the problem
. Recommendations focus on the role …
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psnet.ahrq.gov/node/33922/psn-pdf
August 05, 2009 - The importance of cognitive errors in diagnosis and
strategies to minimize them.
August 5, 2009
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med.
2003;78(8):775-780.
https://psnet.ahrq.gov/issue/importance-cognitive-errors-diagnosis-and-strategies-minimize-them…
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www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac_rates_2019.pdf
January 01, 2019 - Declines in Hospital-Acquired Conditions
Declines in Hospital-
Acquired Conditions
National efforts to reduce hospital-acquired conditions such
as adverse drug events and injuries from falls helped prevent
20,500 deaths and saved $7.7 billion between 2014 and 2017.
Adverse
Drug
Events
-28%
CAUTI*
-5%…
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psnet.ahrq.gov/node/844060/psn-pdf
June 01, 2016 - Developing a measure of value in health care.
June 1, 2016
Ken Lee KH, Matthew Austin J, Pronovost PJ. Developing a measure of value in health care. Value Health.
2015;19(4):323-325. doi:10.1016/j.jval.2014.12.009.
https://psnet.ahrq.gov/issue/developing-measure-value-health-care
Value-based healthcare is emerging…
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psnet.ahrq.gov/node/862607/psn-pdf
February 14, 2024 - Assessing diagnostic performance.
February 14, 2024
Cosby K, Yang D, Fineberg HV. Assessing diagnostic performance. NEJM Evid.
2024;3(2):EVIDra2300232. doi:10.1056/evidra2300232.
https://psnet.ahrq.gov/issue/assessing-diagnostic-performance
Assessing diagnostic performance to reduce diagnostic errors requires a sh…
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psnet.ahrq.gov/node/45334/psn-pdf
September 07, 2016 - Why 'Universal Precautions' are needed for medication
lists.
September 7, 2016
Shane R. Why 'Universal Precautions' are needed for medication lists. BMJ Qual Saf. 2016;25(9):731-2.
doi:10.1136/bmjqs-2015-005116.
https://psnet.ahrq.gov/issue/why-universal-precautions-are-needed-medication-lists
Despite the support…
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psnet.ahrq.gov/node/39161/psn-pdf
December 09, 2009 - Medication reconciliation at an academic medical center:
implementation of a comprehensive program from
admission to discharge.
December 9, 2009
Murphy EM, Oxencis CJ, Klauck JA, et al. Medication reconciliation at an academic medical center:
implementation of a comprehensive program from admission to discharge. A…
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psnet.ahrq.gov/node/73926/psn-pdf
October 06, 2021 - Good for You, Good for Us, Good for Everybody.
October 6, 2021
Ridge K. London, England: Crown Copyright; 2021. September 22, 2021.
https://psnet.ahrq.gov/issue/good-you-good-us-good-everybody
Overprescribing has attained prominence as a safety issue due to the current opioid epidemic, but it has
long reduced medi…
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www.ahrq.gov/hai/tools/abate/introduction.html
May 01, 2022 - Introduction – Toolkit Overview, Decision Making, and Recommended Prelaunch Activities
This document describes how the Toolkit for Decolonization of non-ICU Patients With Devices was developed. It is presented below in full and in individual sections for your convenience.
Full Document:
Introduction – Too…
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psnet.ahrq.gov/node/41625/psn-pdf
December 02, 2014 - Effects of CPOE on provider cognitive workload: a
randomized crossover trial.
December 2, 2014
Avansino J, Leu MG. Effects of CPOE on provider cognitive workload: a randomized crossover trial.
Pediatrics. 2012;130(3):e547-52. doi:10.1542/peds.2011-3408.
https://psnet.ahrq.gov/issue/effects-cpoe-provider-cognitive-…
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psnet.ahrq.gov/node/46052/psn-pdf
December 19, 2017 - Correlates of the third victim phenomenon.
December 19, 2017
Russ MJ. Correlates of the Third Victim Phenomenon. Psychiatr Q. 2017;88(4):917-920.
doi:10.1007/s11126-017-9511-1.
https://psnet.ahrq.gov/issue/correlates-third-victim-phenomenon
A sentinel event affects patients, their families, clinicians involved, an…