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www.ahrq.gov/hai/pfp/hacrate2013-refs.html
October 01, 2015 - To err is human: building a safer healthcare system. … Toward improving the outcome of pregnancy III - enhancing perinatal health through quality, safety, and
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Mokkarala_103.pdf
June 16, 2008 - Turley, RN, PhD
Abstract
A critical step towards reducing errors in health care is the collection … In
its report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (IOM)
estimated … Since the goal of this
ontology was to index the published literature, we felt it was critical that … computerized physician order entry (CPOE) system, which had a menu of several
possible doses of vasopressin; (iii … Conclusions
and Future Work
A critical step in the direction of reducing errors and adverse events
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www.ahrq.gov/sites/default/files/2025-04/newman-toker2-report.pdf
January 01, 2025 - Diagnostic errors in critical care settings – managing
information overload. … Newman-Toker DE, Rizzo JF III. … A
systematic and critical review of bedside diagnosis in acute vestibular syndrome. … To err is human: building a safer health system. … A critical review. South Med J.
2000;93(2):160-7.
38. Grad A, Baloh RW.
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www.ahrq.gov/sites/default/files/2024-01/mcalearney-report.pdf
January 01, 2024 - to have, and to test
innovative designs that had the potential to alter the status quo and shape a safer … Policy changes
included removing low-likelihood patient cohorts (Class III cardiac risk) from monitoring … Nursing Handovers in
Critical Care: A Retrospective Analysis of Information Content and Function. … “Simple Strategies for Safer Hospitals.” … Nursing Handovers in
Critical Care: A Retrospective Analysis of Information Content and Function.
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www.ahrq.gov/news/events/nac/2020-07-nac/nacmtg071420-minutes.html
November 01, 2020 - Kahn, III M.P.H., Federation of American Hospitals
Omar Lateef, D.O., Rush University Medical Center … Facilities as COVID-19 Skilled Care Centers Can Increase Hospital Capacity and Keep Nursing Home Patients Safer … The COVID-19 pandemic has revealed critical gaps in our knowledge of coordination logistics, the workforce
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www.ahrq.gov/sites/default/files/wysiwyg/news/events/nac/2020-07-nac/nacminutes-071420.pdf
January 01, 2020 - Kahn, III M.P.H., Federation of American Hospitals
Omar Lateef, D.O., Rush University Medical Center … Facilities as COVID-19 Skilled Care Centers Can Increase Hospital Capacity and Keep
Nursing Home Patients Safer … The COVID-19 pandemic has revealed critical gaps in our knowledge of coordination logistics,
the workforce
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www.ahrq.gov/sites/default/files/wysiwyg/funding/training-grants/kaward/kaward-evalreport.pdf
August 01, 2016 - ......................................................................................... 27
iii … for Healthcare Research and Quality's (AHRQ’s) mission is to produce evidence to
make health care safer … for Healthcare Research and Quality's (AHRQ’s) mission is to produce evidence to
make health care safer … formative work to be done that
doesn't necessarily lead to immediate publications, the K Award was critical … Care Medicine
Current Cardiology Reports
Current Diabetes Reviews
Current Opinion in Critical Care
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-126-fullreport.pdf
May 01, 2018 - of serious drug interactions, delirium, serious behavioral
changes, cardiac arrhythmias, and death (Safer … be made explicit and transparent as
part of the public release of CHIPRA deliberations; thus, it is critical … group, or facility:** Can compare: (i) practice sites; (ii) medical or other
professional groups; or (iii … Antipsychotic polypharmacy in psychotic
disorders: A critical review of neurobiology, efficacy, tolerability … Psychiatr Serv 2011; 62:613-8.
23
Safer DJ, Zito JM, DosReis, S.
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www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdf
October 27, 2014 - patient harm since the Institute of Medicine’s
(IOM’s) 1999 publication of To Err Is Human: Building a Safer … RTI estimated that the difference in costs between patients
with hospital-acquired Stage III and Stage … IV pressure ulcers and matched patients without
hospital-acquired Stage III and IV pressure ulcers … Medicare Severity diagnosis-related group (MS-
DRG), sex, race, and age that did NOT have a Stage III … To err is human: building a safer healthcare system.
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www.ahrq.gov/sites/default/files/2024-11/golden-west-report.pdf
January 01, 2024 - One-Page Summary 5
III. Final Report 6
IV. Appendix A: List of Participants 12
V. … post-initiative data can document successes and challenges in reducing
patient risk, which can be critical … To Err is Human: Building a Safer Health System. Washington:
National Academy Press; 1999.
2.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/ps-research-summary-pfe.pdf
April 30, 2025 - Parts I and III were rated positively but Part II (report card) needs refinement. … Arbaje
Johns Hopkins
University
Baltimore, Maryland
R01 HS26599
[Grant]
Making Health Care
Safer … safety to inform physicians, nurses, patients, and families about specific
ways to make healthcare safer … Key Findings/Impact: Understanding quantitative information about probabilities
is critical for health … Anna Beeber
University of
North Carolina
Chapel Hill,
North Carolina
R01 HS26473
[Grant]
A Safer
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www.ahrq.gov/sites/default/files/2025-03/sarkar3-report.pdf
January 01, 2025 - challenges that our projects address are exacerbated in safety-net healthcare settings, which lack critical … assess the extent to which tests have been documented and acted upon by clinicians, share abnormal critical … . .” –
IP
Clear paths of communication critical “The problem is when you spend hours to try to track … Design seeds correspond to the
critical activities clinics perform
In preparation of implementation … Mak Healthc Safer III Crit Anal Exist Emerg
Patient Saf Pract [Internet].
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
January 01, 2005 - Introduction
According to the Institute of Medicine’s (IOM’s) 1999 report, To Err Is
Human: Building a Safer … Effective methods of communication, both among caregivers
and between caregivers and patients, are critical … Err is
human: building a safer health system. … Diagnostic validity
of the Drug Abuse Screening Test in the assessment of
DSM-III drug disorders.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/advisorycouncil/advisorycouncil.pdf
April 01, 2008 - These
individuals used their personal insights, knowledge, and experience to create a
safer environment … iii
Contents
Chapter 1. … The
approach health care systems traditionally take neglects the most critical
member of the team—the … Step 2—Select the Team
The membership of the council is critical to successfully building a partnership … Institute of Medicine, To Err is
Human: Building a Safer Health System.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Johnson.pdf
January 01, 2004 - Weaknesses included (1) safer devices may have been
overlooked, as very few alternative devices were … Ritter III HTM. Evaluating and selecting general-
purpose infusion pumps. … Decisions
about critical events in device-related scenarios as a
function of expertise.
-
www.ahrq.gov/data/apcd/envscan/findings.html
July 01, 2022 - organization whose primary mission is to produce and encourage use of evidence to make health care safer … USHIK contained a repository of APCD File Submission specifications and data elements from 14 States iii … Such efforts are critical to meaningful use of the APCD for measurement. … Since it is critical to ensure that valid cost measures are used to avoid the unintended consequence … iii The 14 States are Colorado, Connecticut, Maine, Maryland, Massachusetts, Minnesota, New Hampshire
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www.ahrq.gov/sites/default/files/2025-03/smith-werner-carayon-report.pdf
January 01, 2025 - Systems Engineering,
University of Wisconsin College of Engineering
Katie Ronk, BS, Data Scientist III … Critical Incident Interviews. … Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton III LJ. … Safer Healthcare - Strategies for the Real World. Springer Open; 2016.
34. Carayon P, Wood KE. … The critical incident technique. Psychological bulletin. 1954;51(4):327.
54.
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/en-bsc-interim-report-2.pdf
July 01, 2024 - Cambridge, MA 02138
EvidenceNOW BSC: Interim Evaluation Report II June 2023 ▌iii … • Capitalizing on existing relationships is critical to the formation of a cooperative. … of the Agency for Healthcare Research and Quality (AHRQ) is to “produce evidence to make
healthcare safer … Cooperative Sustainability
The make-up of the ACC membership was cited as a critical element that may … • Capitalizing on existing relationships is critical to the formation of a cooperative.
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie-rev-0724update.pdf
July 01, 2024 - iii The total number of projects is greater than 54 as some projects used more than one approach to improving … over,
providing that information to pharmacists, and then having pharmacists and physicians
discuss safer … for care delivery organizations for safely and
resiliently operating and maintaining their safety-critical … guidance
or standards documents, military standards, and scientific books or papers relevant
to safety-critical
-
www.ahrq.gov/sites/default/files/2025-02/halamek-report.pdf
January 01, 2025 - Methods: Focus group interviews were used to identify critical patient information at the time of an … ; facilitated familiarity with the display and
thereby reduced the need for training; and archived critical … Triggers present on chart review
Type
Number
of cases
(%)
Category II (indeterminate) or III
(abnormal … We found examples
of champions who were able to lead critical thought processes, create prototypes, … To err is human: building a safer health system.