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psnet.ahrq.gov/issue/procuring-interoperability-achieving-high-quality-connected-and-person-centered-care
September 19, 2018 - Book/Report
Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care.
Citation Text:
Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of M…
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psnet.ahrq.gov/issue/girl-who-died-twice-every-patients-nightmare-libby-zion-case-and-hidden-hazards-hospitals
May 09, 2018 - Book/Report
Classic
The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals.
Citation Text:
The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals. Robins NS…
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psnet.ahrq.gov/issue/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions
March 10, 2021 - Newspaper/Magazine Article
Prevent errors during emergency use of hypertonic sodium chloride solutions.
Citation Text:
Prevent errors during emergency use of hypertonic sodium chloride solutions. ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.
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psnet.ahrq.gov/issue/pain-management-and-prescription-opioid-related-harms-exploring-state-evidence-proceedings
July 05, 2008 - Meeting/Conference Proceedings
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.
Citation Text:
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Works…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/experience/lester-wt-et-al-2009
January 01, 2009 - Lester WT et al. 2009 "Mammography FastTrack: an intervention to facilitate reminders for breast cancer screening across a heterogeneous multi-clinic primary care network."
Reference
Lester WT, Ashburner JM, Grant RW, et al. Mammography FastTrack: an intervention to facilitate reminders for breast can…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/pagliari-c-et-al-2004
January 01, 2004 - Pagliari C et al. 2004 "Electronic Clinical Communications Implementation (ECCI) in Scotland: a mixed-methods programme evaluation."
Reference
Pagliari C, Gilmour M, Sullivan F. Electronic Clinical Communications Implementation (ECCI) in Scotland: a mixed-methods programme evaluation. J Eval Clin Prac…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/chan-d-et-al-2003
January 01, 2003 - Chan D et al. 2003 "An internet-based store-and-forward video home telehealth system for improving asthma outcomes in children."
Reference
Chan D, Callahan C, Sheets S, et al. An internet-based store-and-forward video home telehealth system for improving asthma outcomes in children. AJHP 2003;60(19):1…
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psnet.ahrq.gov/issue/standardized-competencies-parenteral-nutrition-administration-aspen-model
June 12, 2018 - Organizational Policy/Guidelines
Standardized Competencies for Parenteral Nutrition Administration: the ASPEN Model.
Citation Text:
Guenter P, Worthington P, Ayers P, et al. Standardized Competencies for Parenteral Nutrition Administration: The ASPEN Model. Nutr Clin Pract. 2018;33(2):29…
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psnet.ahrq.gov/issue/improving-handoffs-emergency-department
July 19, 2017 - Commentary
Improving handoffs in the emergency department.
Citation Text:
Cheung DS, Kelly JJ, Beach C, et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55(2):171-80. doi:10.1016/j.annemergmed.2009.07.016.
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psnet.ahrq.gov/issue/american-college-endocrinology-and-american-association-clinical-endocrinologists-position
August 20, 2018 - Commentary
American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology.
Citation Text:
Bates DW, Clark NG, Cook RI, et al. American College of Endocrinology and Amer…
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digital.ahrq.gov/ahrq-funded-projects/value-health-information-exchange-ambulatory-care
January 01, 2023 - Value of Health Information Exchange in Ambulatory Care
Project Final Report ( PDF , 97.39 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ…
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psnet.ahrq.gov/issue/how-surgical-trainees-handle-catastrophic-errors-qualitative-study
March 19, 2019 - Study
How surgical trainees handle catastrophic errors: a qualitative study.
Citation Text:
Balogun JA, Bramall AN, Bernstein M. How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study. J Surg Educ. 2015;72(6):1179-84. doi:10.1016/j.jsurg.2015.05.003.
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www.ahrq.gov/patient-safety/reports/engage/medlist.html
October 01, 2022 - Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
Create a Safe Medicine List Together
"A lot of times patients come in and say, "I take a white pill or I take a purple pill or a green pill" and I have no idea what it is or how much they are taking. This strategy hel…
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psnet.ahrq.gov/issue/telehealth
January 27, 2019 - Commentary
Telehealth.
Citation Text:
Tuckson R, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585-1592. doi:10.1056/NEJMsr1503323.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/principles-pediatric-patient-safety-reducing-harm-due-medical-care
May 22, 2019 - Organizational Policy/Guidelines
Principles of pediatric patient safety: reducing harm due to medical care.
Citation Text:
Mueller BU, Neuspiel DR, Fisher ERS, et al. Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care. Pediatrics. 2019;143(2):e20183649. doi:10.1542…
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psnet.ahrq.gov/issue/errors-medicine-punishment-versus-learning-medical-adverse-events-revisited-expanding-frame
August 24, 2022 - Review
Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame.
Citation Text:
Brattebø G, Flaatten HK. Errors in medicine: punishment versus learning medical adverse events revisited – expanding the frame. Curr Opin Anaesthesiol. 2023;36(2):…
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hcup-us.ahrq.gov/db/state/sidrelatedreports.jsp
July 01, 2016 - SID Related Reports
An official website of the Department of Health & Human Services
Search All AHRQ Websites
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Implement_Hndbook_508_v2.docx
January 28, 2011 - patient safety and quality-related issues, including acknowledging issues that are ongoing problems requiring
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-193-disposition-comments-naloxone.pdf
November 27, 2017 - ES-10, line 27: I would temper the claim that
“persons who refuse transport or are assessed
as not requiring … to not be aware of taking higher
potency synthetic opiates and there are case reports
of patients requiring … the
prevalence of overdoses
associated with high
potency opioids or the
proportion of patients
requiring … Response
Peer Reviewer
#3
Discussion/
Conclusion
Page 24, line 55-56 – Consider changing
“requiring
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www.ahrq.gov/sites/default/files/2024-07/gallagher5-report.pdf
January 01, 2024 - reportable to the National Practitioner Data Bank (NPDB), which physicians consider an onerous
“black mark” requiring