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digital.ahrq.gov/program-overview/research-stories/safer-inter-hospital-transfers-improving-access-health
January 01, 2023 - Safer Inter-Hospital Transfers by Improving Access to Health Information
Theme:
Supporting Health Systems in Advancing Care Delivery
Subtheme:
Using Digital Healthcare Tools to Improve Patient Safety
An enhanced health information exchange platform that improves workflow, interoperability,…
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digital.ahrq.gov/organization/university-washington
January 01, 2023 - University of Washington
Preventing Medication-Related Problems in Care Transitions to Skilled Nursing Facilities
Description
This research aims to determine the effectiveness of a program designed to reduce medication-related issues among patients during the hospital-to-skill…
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psnet.ahrq.gov/issue/swift-new-tool-identifying-prospective-hazards
February 03, 2021 - Commentary
Beyond FMEA: the structured what-if technique (SWIFT).
Citation Text:
Card AJ, Ward JR, Clarkson PJ. Beyond FMEA: The structured what-if technique (SWIFT). J Healthc Risk Manag. 2012;31(4):23-29. doi:10.1002/jhrm.20101.
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psnet.ahrq.gov/issue/spectrum-medical-errors-when-patients-sue
October 28, 2020 - Review
The spectrum of medical errors: when patients sue.
Citation Text:
Grant-Kels J, Kels B. The spectrum of medical errors: when patients sue. Int J Gen Med. 2012. doi:10.2147/ijgm.s24257.
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-2.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 6.2. Horizon Hospital—Lakeview Healthcare
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Case 2. C…
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www.ahrq.gov/news/blog/ahrqviews/shaping-the-future-through-dhr.html
September 01, 2024 - AHRQ Views: Blog posts from AHRQ leaders
Shaping the Future of Patient Empowerment and Care Delivery Through Digital Healthcare Research
SEP
24
2024
By
Chris
Dymek,
Ed.D.
Chris Dymek, Ed.D.
Providing healthcare consumers with evidence-based insights and p…
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psnet.ahrq.gov/issue/incidence-diagnostic-error-medicine
July 15, 2015 - Review
The incidence of diagnostic error in medicine.
Citation Text:
Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013;22 Suppl 2:ii21-ii27. doi:10.1136/bmjqs-2012-001615.
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digital.ahrq.gov/location/usa-ct-new-haven
January 01, 2023 - USA, CT, New Haven
Using Electronic Health Records to Support Decision-Making in Pediatric Obesity Care
Description
This project will evaluate and compare different tools within electronic health records to assist pediatric primary care clinicians with providing higher quality…
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psnet.ahrq.gov/issue/senior-staff-safety-rounds-commitment-ensure-safety-top-priority
May 30, 2018 - Commentary
Senior staff safety rounds: a commitment to ensure safety is the top priority.
Citation Text:
Senior staff safety rounds: a commitment to ensure safety is the top priority. O'Connell RT, Ivy ME. NEJM Catalyst. May 1, 2018.
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psnet.ahrq.gov/issue/root-cause-analysis-core-problem-solving-and-corrective-action-second-edition
June 09, 2011 - Book/Report
Classic
Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition.
Citation Text:
Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition. Oakes D. Milwaukee, WI: ASQ Quality Press; 2019. IS…
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psnet.ahrq.gov/issue/major-congenital-malformations-after-first-trimester-exposure-ace-inhibitors
July 10, 2008 - Study
Major congenital malformations after first-trimester exposure to ACE inhibitors.
Citation Text:
Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. Major Congenital Malformations after First-Trimester Exposure to ACE Inhibitors. New England Journal of Medicine. 2006;354(23). doi:10.…
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psnet.ahrq.gov/issue/rethinking-rapid-response-teams
February 23, 2019 - Commentary
Rethinking rapid response teams.
Citation Text:
Litvak E, Pronovost P. Rethinking rapid response teams. JAMA. 2010;304(12):1375-6. doi:10.1001/jama.2010.1385.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
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psnet.ahrq.gov/issue/risk-models-improve-safety-dispensing-high-alert-medications-community-pharmacies
December 02, 2020 - Study
Risk models to improve safety of dispensing high-alert medications in community pharmacies.
Citation Text:
Cohen MR, Smetzer JL, Westphal JE, et al. Risk models to improve safety of dispensing high-alert medications in community pharmacies. J Am Pharm Assoc (2003). 2012;52(5):584-6…
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psnet.ahrq.gov/issue/improving-usability-intravenous-medication-labels-support-safe-medication-delivery
September 26, 2016 - Study
Improving the usability of intravenous medication labels to support safe medication delivery.
Citation Text:
Bauer DT, Guerlain S. Improving the usability of intravenous medication labels to support safe medication delivery. International journal of industrial ergonomics. 2011;41…
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psnet.ahrq.gov/issue/recent-evidence-health-it-improves-patient-safety-issue-brief
June 29, 2016 - Book/Report
Recent Evidence That Health IT Improves Patient Safety: Issue Brief.
Citation Text:
Recent Evidence That Health IT Improves Patient Safety: Issue Brief. Banger A, Graber ML. Washington, DC: Office of the National Coordinator for Health Information Technology; February 2015.
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psnet.ahrq.gov/issue/patient-safety-20-slaying-dragons-not-just-investigating-them
September 14, 2016 - Commentary
Patient safety 2.0: slaying dragons, not just investigating them.
Citation Text:
Card AJ. Patient safety 2.0: slaying dragons, not just investigating them. J Patient Saf. 2023;19(6):394-395. doi:10.1097/pts.0000000000001140.
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psnet.ahrq.gov/issue/system-related-factors-contributing-diagnostic-errors
January 11, 2023 - Review
System-related factors contributing to diagnostic errors.
Citation Text:
Thammasitboon S, Thammasitboon S, Singhal G. System-related factors contributing to diagnostic errors. Curr Probl Pediatr Adolesc Health Care. 2013;43(9):242-7. doi:10.1016/j.cppeds.2013.07.004.
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psnet.ahrq.gov/issue/identification-errors-pathology-and-laboratory-medicine
October 19, 2022 - Commentary
Identification errors in pathology and laboratory medicine.
Citation Text:
Valenstein PN, Sirota RL. Identification errors in pathology and laboratory medicine. Clin Lab Med. 2004;24(4):979-96, vii.
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/synthesis-report/conclusions.html
October 01, 2015 - Findings From the AHRQ Transforming Primary Care Grant Initiative: A Synthesis Report
Conclusions and Implications
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Table of Contents
Findings From the AHRQ Transforming Primary Care Grant Initiative: A Synthesis Report
Executive Summary
Introduction
Methods
Overview o…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb6.html
February 01, 2023 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Appendix B11: Fall Interventions Plan
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Table of Contents
The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Chapter 1. Introduction and Program Overview
…