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psnet.ahrq.gov/node/862137/psn-pdf
February 07, 2024 - What do parents think about the quality and safety of care
provided by hospitals to children and young people with
an intellectual disability? A qualitative study using
thematic analysis.
February 7, 2024
Ong N, Lucien A, Long JC, et al. What do parents think about the quality and safety of care provided by
hospi…
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psnet.ahrq.gov/node/46624/psn-pdf
November 29, 2017 - Empowerment failure: how shortcomings in physician
communication unwittingly undermine patient autonomy.
November 29, 2017
Ubel PA, Scherr KA, Fagerlin A. Empowerment Failure: How Shortcomings in Physician Communication
Unwittingly Undermine Patient Autonomy. Am J Bioeth. 2017;17(11):31-39.
doi:10.1080/15265161.20…
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psnet.ahrq.gov/node/39056/psn-pdf
April 04, 2011 - Rate of undesirable events at beginning of academic year:
retrospective cohort study.
April 4, 2011
Haller G, Myles PS, Taffé P, et al. Rate of undesirable events at beginning of academic year: retrospective
cohort study. BMJ. 2009;339:b3974. doi:10.1136/bmj.b3974.
https://psnet.ahrq.gov/issue/rate-undesirable-eve…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/contingency-diagram
January 01, 2023 - Contingency Diagram
Description
The contingency diagram uses brainstorming to generate a list of problems that could arise from a process. Once problems are identified, then solutions to the problems are determined.
Uses
When identifying causes of potential problems.
When developing soluti…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/requirement-and-measures-tree
January 01, 2023 - Requirements and Measures Tree
Description
The requirements and measures tree is a method for organizing customers, customer requirements, and related data for a product or service. The tree allows for a vsual representation of the relationships between these elements.
Uses
To visually repre…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/value-added-analysis
January 01, 2023 - Value-Added Analysis
Description
Value-added analysis is a method for identifying problems within a process. The analysis allows a team to examine individual process steps so it can separate the steps that add value for the user from the steps that do not.
Uses
When searching for sources of …
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psnet.ahrq.gov/node/50458/psn-pdf
October 09, 2019 - Success of a resident-led safety council: a model for
satisfying CLER Pathways to Excellence patient safety
goals.
October 9, 2019
Cohen SP, Pelletier JH, Ladd JM, et al. Success of a resident-led safety council: a model for satisfying
CLER Pathways to Excellence patient safety goals. J Gen Intern Med. 2019;11(2):…
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psnet.ahrq.gov/node/37290/psn-pdf
February 15, 2011 - Medical errors involving trainees: a study of closed
malpractice claims from 5 insurers.
February 15, 2011
Singh H, Thomas EJ, Petersen L, et al. Medical errors involving trainees: a study of closed malpractice
claims from 5 insurers. Arch Intern Med. 2007;167(19):2030-6.
https://psnet.ahrq.gov/issue/medical-error…
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psnet.ahrq.gov/node/41101/psn-pdf
October 16, 2012 - System-related interventions to reduce diagnostic errors:
a narrative review.
October 16, 2012
Singh H, Graber ML, Kissam SM, et al. System-related interventions to reduce diagnostic errors: a
narrative review. BMJ Qual Saf. 2012;21(2):160-170. doi:10.1136/bmjqs-2011-000150.
https://psnet.ahrq.gov/issue/system-rel…
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psnet.ahrq.gov/node/39499/psn-pdf
January 03, 2017 - Caring for our own: deploying a systemwide second
victim rapid response team.
January 3, 2017
Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid
response team. Jt Comm J Qual Saf. 2010;36(5):233-240.
https://psnet.ahrq.gov/issue/caring-our-own-deploying-systemwi…
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psnet.ahrq.gov/node/46361/psn-pdf
May 23, 2018 - Inadequate hand-off communication.
May 23, 2018
Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6.
https://psnet.ahrq.gov/issue/inadequate-hand-communication
The Joint Commission publishes sentinel event alerts to draw attention to pressing or emerging safety
issues and provide guidelines fo…
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psnet.ahrq.gov/node/45067/psn-pdf
May 11, 2016 - Hospital Survey on Patient Safety Culture: 2016 User
Comparative Database Report.
May 11, 2016
Famolaro T, Yount ND, Burns W, Flashner E, Liu H, Sorra J. Rockville, MD: Agency for Healthcare
Research and Quality; March 2016. AHRQ Publication No. 16-00121-EF.
https://psnet.ahrq.gov/issue/hospital-survey-patient-saf…
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psnet.ahrq.gov/issue/african-partnerships-patient-safety
April 30, 2024 - Multi-use Website
African Partnerships for Patient Safety.
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
Linkedin
Copy URL
November 11, 2009
This Web site establishes a forum for hospitals in E…
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psnet.ahrq.gov/node/37114/psn-pdf
October 04, 2011 - A descriptive study of morbidity and mortality
conferences and their conformity to medical incident
analysis models: results of the morbidity and mortality
conference improvement study, phase 1.
October 4, 2011
Aboumatar HJ, Blackledge CG, Dickson C, et al. A descriptive study of morbidity and mortality conference…
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psnet.ahrq.gov/node/866691/psn-pdf
September 11, 2024 - Unlocking the potential of free text in electronic health
records with large language models (LLM): enhancing
patient safety and consultation interactions.
September 11, 2024
Kumarapeli P, Haddad T, de Lusignan S. Unlocking the potential of free text in electronic health records
with large language models (LLM): e…
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psnet.ahrq.gov/node/60174/psn-pdf
March 30, 2020 - Making Healthcare Safer III Report
March 30, 2020
Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
What is the Making Healthcare Safer Report?
The Making Healthcare Safer Report represents an ef…
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www.ahrq.gov/research/findings/final-reports/ssi/ssiapo.html
April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection
Appendix O. Nursing Focus Group Guides
Previous Page Next Page
Table of Contents
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection
Executive Summary
Chapter 1. Admi…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teachback_webinar_slides.pdf
November 08, 2016 - Teach-back
1
Teach-Back
AHRQ
Guide to Improving Patient Safety in Primary
Care Settings by Engaging Patients and
Families
Speaker
Kelly Smith, PhD
Scientific Director, Quality & Safety
Co-PI, AHRQ Guide to Improve Patient
Safety in Primary Care Settings by Engaging
Patients and Families
kell…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/infection-prevention/precautions/ppe-slides.html
March 01, 2017 - Personal Protective Equipment
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Slide 1: Personal Protective Equipment
Training Module 3
Slide 2: Learning Objectives
Upon completion of this training, long-term care facility staff will be able to—
Describe when to use personal protective equipme…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/mui/care-pathway.pdf
June 02, 2025 - Urinary Incontinence Care Pathway
```
Urinary Incontinence
Care Pathway
EMPOWER Team – University
Hospitals of Cleveland
This project was funded under grant number 1U18HS0…