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psnet.ahrq.gov/node/37466/psn-pdf
May 27, 2011 - Medication administration variances before and after
implementation of computerized physician order entry in
a neonatal intensive care unit.
May 27, 2011
Taylor JA, Loan LA, Kamara J, et al. Medication administration variances before and after implementation
of computerized physician order entry in a neonatal inte…
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psnet.ahrq.gov/node/46622/psn-pdf
December 06, 2017 - White paper on recommendation for systems-based
practice competency.
December 6, 2017
Stalter AM, Phillips JM, Dolansky MA. QSEN Institute RN-BSN Task Force: White Paper on
Recommendation for Systems-Based Practice Competency. J Nurs Care Qual. 2017;32(4):354-358.
doi:10.1097/NCQ.0000000000000262.
https://psnet.a…
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psnet.ahrq.gov/node/34786/psn-pdf
March 28, 2005 - Errors in drug computations during newborn intensive
care.
March 28, 2005
Perlstein PH, Callison C, White M, et al. Errors in Drug Computations During Newborn Intensive Care. Arch
Pediatr Adolesc Med. 1979;133(4):376-379. doi:10.1001/archpedi.1979.02130040030006.
https://psnet.ahrq.gov/issue/errors-drug-computatio…
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psnet.ahrq.gov/node/45099/psn-pdf
December 07, 2018 - Improving Patient Safety in Ambulatory Surgery Centers:
A Resource List for Users of the AHRQ Ambulatory
Surgery Center Survey on Patient Safety Culture.
December 7, 2018
Rockville, MD; Agency for Healthcare Quality and Research; March 2016.
https://psnet.ahrq.gov/issue/improving-patient-safety-ambulatory-surgery-…
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psnet.ahrq.gov/node/837516/psn-pdf
June 22, 2022 - Fostering ethical conduct through psychological safety.
June 22, 2022
Ferrere A, Rider C, Renerte B et al. Sloan Manag Rev. Summer 2022;39-43.
https://psnet.ahrq.gov/issue/fostering-ethical-conduct-through-psychological-safety
A baseline expectation in a safe organization is that employees feel comfortable and supp…
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psnet.ahrq.gov/node/73298/psn-pdf
May 19, 2021 - The Future of Nursing 2020-2030: Charting a Path to
Achieve Health Equity.
May 19, 2021
National Academies of Sciences, Engineering, and Medicine. Washington DC: National
Academies Press; 2021. ISBN: 9780309685061.
https://psnet.ahrq.gov/issue/future-nursing-2020-2030-charting-path-achieve-he…
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psnet.ahrq.gov/node/46562/psn-pdf
April 16, 2018 - "To err is human" but disclosure must be taught: a
simulation-based assessment study.
April 16, 2018
Crimmins AC, Wong AH, Bonz JW, et al. "To Err Is Human" but Disclosure Must be Taught: A Simulation-
Based Assessment Study. Simul Healthc. 2018;13(2):107-116. doi:10.1097/SIH.0000000000000273.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/36069/psn-pdf
May 11, 2014 - Health literacy, medication errors, and health outcomes:
is there a relationship?
May 11, 2014
Warner A, Menachemi N, Brooks RG. Health Literacy, Medication Errors, and Health Outcomes: Is There a
Relationship? Hosp Pharm. 2010;41(6):542-551. doi:10.1310/hpj4106-538.
https://psnet.ahrq.gov/issue/health-literacy-me…
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psnet.ahrq.gov/node/866318/psn-pdf
July 17, 2024 - Methods to increase reliability in quality improvement
projects.
July 17, 2024
Lenk MA, LaMantia S, Oehler J, et al. Methods to increase reliability in quality improvement projects. Hosp
Pediatr. 2024;14(8):e372-e377. doi:10.1542/hpeds.2023-007340.
https://psnet.ahrq.gov/issue/methods-increase-reliability-quality-…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/child-hcahps-ahrq-program.pdf
June 02, 2025 - Introducing the Child HCAHPS® Survey Database webcast-Ginsberg
WELCOME FROM AHRQ
Caren Ginsberg, PhD
Director, CAHPS & SOPS Programs
Center for Quality Improvement & Patient Safety, AHRQ
AHRQ and the CAHPS Program
• AHRQ is:
► A research and science-based agency of the US Department of Health
and Human Servi…
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psnet.ahrq.gov/node/843053/psn-pdf
January 25, 2023 - The safety of inpatient health care.
January 25, 2023
Bates DW, Levine DM, Salmasian H, et al. The safety of inpatient health care. New Engl J Med.
2023;388(2):142-153. doi:10.1056/nejmsa2206117.
https://psnet.ahrq.gov/issue/safety-inpatient-health-care
An accurate understanding of the frequency, severity, and pre…
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psnet.ahrq.gov/node/47860/psn-pdf
June 30, 2019 - New mother number 14.
June 30, 2019
Sangarlangkarn A. Healthc (Amst). 2019;7:31-32.
https://psnet.ahrq.gov/issue/new-mother-number-14
Rigid adherence to protocols may detract from safety when unexpected critical events occur that require
deviation from the standard process. This commentary explores insights from a…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-120-section-6b-table-6.pdf
June 02, 2025 - Section 6-B, Table 6
TABLE 6
HROB Summary (Combined Unduplicated)
New York State Medicaid, 2010
Urbanicity UIC N OB
Proxy1
Transfusion
Proxy2
NICU
>=33
URBAN
Large
Metropolitan
1 48,562 27.10% 14.62% 37.98%
Small
Metropolitan
2 7229 15.95% 10.26% 21.69%
RURAL
Adjacent to Lar…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0121-table-6.pdf
June 02, 2025 - Table 6 - HROB Summary
TABLE 6
HROB Summary (Combined Unduplicated)
New York State Medicaid, 2010
Urbanicity UIC N OB
Proxy1
Transfusion
Proxy2
NICU
>=33
URBAN
Large
Metropolitan
1 48,562 27.10% 14.62% 37.98%
Small
Metropolitan
2 7229 15.95% 10.26% 21.69%
RURAL
Adjacent to L…
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-123-section-6-table-6.pdf
June 02, 2025 - CHIPRA 123: Section 6, Table 6
TABLE 6
HROB Summary (Combined Unduplicated)
New York State Medicaid, 2010
Urbanicity UIC N OB
Proxy1
Transfusion
Proxy2
NICU
>=33
URBAN
Large
Metropolitan
1 48,562 27.10% 14.62% 37.98%
Small
Metropolitan
2 7229 15.95% 10.26% 21.69%
RURAL
Adjac…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-h.docx
June 02, 2025 - Remove that Foley
AHRQ Safety Program for Reducing CAUTI in Hospitals
Appendix H. Urinary Catheter Pocket Card
Front
Front
Back
Remove that Urinary Catheter!
Foley catheters can cause:
· Infections
· Length of Stay
· Cost
· Patient Discomfort
· Antibiotic Use
Urinary catheters confine patients to bed, …
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams-7.html
July 01, 2023 - Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety
Barriers
Previous Page Next Page
Table of Contents
Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety
Introduction
The Patient-Clinician Dyad
…
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psnet.ahrq.gov/node/46988/psn-pdf
April 25, 2018 - Opioid Stewardship.
April 25, 2018
Ochsner J. 2018;18(1):20-45.
https://psnet.ahrq.gov/issue/opioid-stewardship
Both organizational and national strategies are required to reduce opioid-related harm. This special issue
section explores one health system's efforts to address the opioid epidemic. Articles discuss em…
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effectivehealthcare.ahrq.gov/sites/default/files/delilberative-methods-design-abelson-2.pdf
May 29, 2025 - Synthesizing the Outputs of Deliberative Forum
Synthesizing the Outputs of Deliberative Forum
Julia Abelson, PhD
Department of Clinical Epidemiology & Biostatistics
McMaster University
Hamilton, Ontario CANADA
Slide 27
Linking deliberation objectives to outputs
What is the expected deliverable of th…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/health-it-survey-compendium/survey-kentucky-ambulatory-network-members
January 01, 2023 - Survey of Kentucky Ambulatory Network Members' Use of Information Technology: Office Manager Survey
This is a questionnaire designed to be completed by administrators in an ambulatory setting. The tool includes questions to assess the current state of electronic health records and practice management syst…