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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-sustainability-centers-of-excellence1.html
April 01, 2025 - Four Pillars for Sustainable Centers of Excellence
Introduction
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Table of Contents
Four Pillars for Sustainable Centers of Excellence
Introduction
Center of Excellence Operations
Alignment
Integration
Leadership Support
Windows of Opportunity
Conclusion
Acknowl…
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psnet.ahrq.gov/issue/telemedicine-ensuring-safe-equitable-person-centered-virtual-care
March 29, 2006 - Book/Report
Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care.
Citation Text:
Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care. Perry AF, Federico F, Huebner J. Boston, MA: Institute for Healthcare Improvement; 2021.
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integrationacademy.ahrq.gov/expert-insight/niac-video/10871
January 01, 2013 - An official website of the Department of Health & Human Services
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psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition
January 27, 2016 - Book/Report
Classic
Respectful Management of Serious Clinical Adverse Events. Second Edition.
Citation Text:
Respectful Management of Serious Clinical Adverse Events. Second Edition. Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Heal…
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psnet.ahrq.gov/issue/maryland-hospital-patient-safety-program-annual-report
December 24, 2008 - Book/Report
Maryland Hospital Patient Safety Program Annual Report.
Citation Text:
Maryland Hospital Patient Safety Program Annual Report. Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.
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psnet.ahrq.gov/issue/educational-opportunities-postevent-debriefing
May 28, 2015 - Commentary
Educational opportunities with postevent debriefing.
Citation Text:
Mullan PC, Kessler DO, Cheng A. Educational opportunities with postevent debriefing. JAMA. 2014;312(22):2333-4. doi:10.1001/jama.2014.15741.
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psnet.ahrq.gov/issue/report-mid-staffordshire-nhs-foundation-trust-public-inquiry
November 06, 2015 - Book/Report
Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry.
Citation Text:
Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry. Francis R. London, UK: The Stationary Office; 2013. ISBN: 9780102981469.
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psnet.ahrq.gov/issue/vanishing-nonforensic-autopsy
February 09, 2011 - Commentary
The vanishing nonforensic autopsy.
Citation Text:
Shojania KG, Burton EC. The vanishing nonforensic autopsy. N Engl J Med. 2008;358(9):873-5. doi:10.1056/NEJMp0707996.
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psnet.ahrq.gov/issue/engineering-patient-safety-radiation-oncology-university-north-carolinas-pursuit-high
May 04, 2016 - Book/Report
Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation.
Citation Text:
Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. M…
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psnet.ahrq.gov/issue/radiation-therapy-safety-critical-role-radiation-therapist
June 20, 2014 - Book/Report
Radiation Therapy Safety: The Critical Role of the Radiation Therapist.
Citation Text:
Radiation Therapy Safety: The Critical Role of the Radiation Therapist. Odle TG, Rosier N. Albuquerque, NM: American Society of Radiologic Technologists Education and Research Foundatio…
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psnet.ahrq.gov/issue/how-insight-contributes-diagnostic-excellence
June 08, 2022 - Commentary
How insight contributes to diagnostic excellence.
Citation Text:
Shimizu T, Graber ML. How insight contributes to diagnostic excellence. Diagnosis (Berl). 2022;9(3):311-315. doi:10.1515/dx-2022-0007.
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psnet.ahrq.gov/issue/concept-analysis-systems-thinking
August 20, 2018 - Review
A concept analysis of systems thinking.
Citation Text:
Stalter AM, Phillips JM, Ruggiero JS, et al. A Concept Analysis of Systems Thinking. Nurs Forum. 2017;52(4):323-330. doi:10.1111/nuf.12196.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/engaging-nurse-physician-patient-transcript.docx
June 02, 2025 - On the CUSP: Stop CAUTI in ICU
June 10 ICU Content Call
Chelsea: Excuse me, everyone. We now have all of our speakers in conference. Please be aware that each of your lines is in a listen only mode. At the conclusion of today's presentation, we will open the floor for questions. At that time, instructions will be give…
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www.ahrq.gov/hai/cauti-tools/archived-webinars/engaging-nurse-physician-patient-transcript.html
December 01, 2017 - Engaging the Nurse, Physician, Patient/Family, CUSP: Learn From Defects
Webinar Transcript
On the CUSP: Stop CAUTI in ICU
June 10, 2015 ICU Content Call
Chelsea: Excuse me, everyone. We now have all of our speakers in conference. Please be aware that each of your lines is in a listen only mode. At the con…
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integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/plan-integrate-mat-for-oud/understanding-components-of-mat
February 01, 2025 - An official website of the Department of Health & Human Services
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psnet.ahrq.gov/node/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - SPOTLIGHT CASE
Discharged with IV antibiotics: When issues arise, who manages the complications?
Citation Text:
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - Root Cause Analysis Gone Wrong
May 1, 2018
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
The Case
A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney
transplant. A suitabl…
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psnet.ahrq.gov/node/33806/psn-pdf
April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of
Pediatrics a…
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psnet.ahrq.gov/web-mm/standard-deviations
January 01, 2006 - SPOTLIGHT CASE
Standard Deviations
Citation Text:
Sabin JE. Standard Deviations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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