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psnet.ahrq.gov/node/45073/psn-pdf
May 11, 2016 - Promoting patient safety: results of a TeamSTEPPS
initiative.
May 11, 2016
Gaston T, Short N, Ralyea C, et al. Promoting patient safety: results of a TeamSTEPPS initiative. J Nurs
Adm. 2016;46(4):201-207. doi:10.1097/nna.0000000000000333.
https://psnet.ahrq.gov/issue/promoting-patient-safety-results-teamstepps-ini…
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psnet.ahrq.gov/node/60893/psn-pdf
January 01, 2021 - When safety event reporting is seen as punitive: "I've
been PSN-ed!"
September 9, 2020
Feeser VR, Jackson AK, Savage NM, et al. When safety event reporting is seen as punitive: "I've been
PSN-ed!". Ann Emerg Med. 2021;77(4):449-458. doi:10.1016/j.annemergmed.2020.06.048.
https://psnet.ahrq.gov/issue/when-safety-ev…
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psnet.ahrq.gov/node/46671/psn-pdf
June 25, 2018 - Twelve tips for embedding human factors and
ergonomics principles in healthcare education.
June 25, 2018
Vosper H, Hignett S, Bowie P. Twelve tips for embedding human factors and ergonomics principles in
healthcare education. Med Teach. 2017;40(4):357-363. doi:10.1080/0142159x.2017.1387240.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/46181/psn-pdf
January 01, 2019 - Increasing patient–clinician concordance about medical
error disclosure through the patient TIPS model.
July 12, 2017
Martinez W, Browning D, Varrin P, et al. Increasing Patient-Clinician Concordance About Medical Error
Disclosure Through the Patient TIPS Model. J Patient Saf. 2019;15(4):305-307.
doi:10.1097/PTS.0…
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psnet.ahrq.gov/node/39504/psn-pdf
May 05, 2010 - Patient whiteboards as a communication tool in the
hospital setting: A survey of practices and
recommendations.
May 5, 2010
Sehgal NL, Green A, Vidyarthi A, et al. Patient whiteboards as a communication tool in the hospital setting:
a survey of practices and recommendations. J Hosp Med. 2010;5(4):234-9. doi:10.100…
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www.ahrq.gov/patient-safety/settings/hospital/match/table-5.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Table 5: Identifying Challenges and Addressing Barriers
Previous Page Next Page
Table of Contents
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Introducti…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/aph.html
August 01, 2022 - Event Investigation and Analysis Guide: Appendix H
Hierarchy of Solutions
Do solutions meet the following criteria:
Address the root cause/contributing factor.
Are specific and concrete.
Can be understood and implemented by a reader unfamiliar with the situation.
Will be tested or simulated prior to…
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psnet.ahrq.gov/node/45249/psn-pdf
June 22, 2016 - PHSO Review: Quality of NHS Complaints Investigations.
June 22, 2016
First Report of Session 2016–17 Report. House of Commons Public Administration and Constitutional
Affairs Committee. London, England: The Stationery Office; May 24, 2016. Publication HC 94.
https://psnet.ahrq.gov/issue/phso-review-quality-nhs-comp…
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psnet.ahrq.gov/node/72486/psn-pdf
November 18, 2020 - ISMP Survey provides insights into preparation and
admixture practices OUTSIDE the pharmacy.
November 18, 2020
ISMP Medication Safety Alert! Acute care edition. November 5, 2020;25(22)1-5.
https://psnet.ahrq.gov/issue/ismp-survey-provides-insights-preparation-and-admixture-practices-outside-
pharmacy
Mistakes in …
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www.ahrq.gov/evidencenow/tools/root-cause-analysis.html
February 01, 2025 - Using Root Cause Analysis to Improve Quality and Performance
Resource: Using Root Cause Analysis to Help Practices Understand and Improve Their Performance and Outcomes (PDF, 908 KB, 18 pages) Part of an AHRQ curriculum used to train practice facilitators, this resource describes how practices can use a roo…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/lifecycle-assessment-disposition-comments.pdf
November 20, 2024 - Disposition of Comments_Technical Brief No. 48_Use of Life Cycle Assessment in the Healthcare Industry: Environmental Impacts and Emissions Associated With Products, Processes and Waste
Technical Brief Disposition of Comments Report
Title: Use of Life Cycle Assessment in the Healthcare Industry: Environmental Impac…
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www.ahrq.gov/sites/default/files/2024-01/lambert-report.pdf
January 01, 2024 - Final Progress Report: TOP-MEDS CERT: Tools for Optimizing Medication Safety
Principal Investigator: Lambert, Bruce L. (Grant No. U19HS021093)
Northwestern University
TOP-MEDS CERT: Tools for Optimizing Medication Safety
Final Report, September 1, 2011, to August 30, 2017
Submitted November 20, 2017
This proje…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/nursing-home/2025-nursing-home-database-report-pt1.pdf
January 01, 2025 - Surveys on Patient Safety Culture (SOPS) Nursing Home Survey: 2025 User Database Report Part I
e
SURVEYS ON PATIENT SAFETY CULTURE®(SOPS)®
Nursing Home Survey:
2025 User Database Report
Surveys on
Patient Safety
Culture®
PATIENT
SAFETY
[This page intentionally left blank]
Surveys on Patient Safety Cultu…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/fetal-surgery_disposition-comments.pdf
July 05, 2011 - Peer Reviewer
#3
Results Similarly, the statement “In the United States, pediatric
surgeons are trained
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/impguide.html
December 01, 2014 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Facilitator Training Instructor Guide—Implementation of the Prevention Reports
Note: This part of the training primarily consists of exercises and does not have any associated slides.
Introduction
Say:
Yesterday you were introdu…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving.pptx
May 01, 2017 - Improving Communication and Teamwork in the Surgical Environment
Improving Communication and Teamwork in the Surgical Environment Module
AHRQ Safety Program for Ambulatory Surgery
AHRQ Pub. No. 16(17)-0019-2-EF
May 2017
Communication and Teamwork | ‹#›
AHRQ Safety Program for Ambulatory Surgery
1
Objectives
…
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www.ahrq.gov/research/findings/factsheets/children/new-starts/2011.html
October 01, 2014 - Fiscal Year 2011 Research on Child and Adolescent Health
New Starts
This fact sheet summarizes new grants and contracts focused on child and adolescent health and health care—including research, conference, and training projects, as well as other initiatives—funded in FY 2011 by the Agency for Hea…
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digital.ahrq.gov/sites/default/files/docs/publication/r03hs018220-fleming-final-report-2011.pdf
January 01, 2011 - Exploring Financial and Non-Financial Costs and Benefits of Health Information Technology: The Impact of an Ambulatory Electronic Health Record on Financial and Workflow in Primary Care Practices and Costs of Implementation
Grant Final Report
Grant ID: R03HS018220-01
Exploring Financial and Non-Financial …
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www.ahrq.gov/sites/default/files/publications/files/planningtool_0.pdf
January 01, 2016 - AHRQ Surveys on Patient Safety Culture
Examples of process measures include:
Number of staff trained
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www.ahrq.gov/sites/default/files/2024-07/gallagher4-report.pdf
January 01, 2024 - the clinical realism, a
Page 8 of 11 Final Report: 5K08HS014012-03
"standardized team member" (trained