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www.ahrq.gov/evidencenow/projects/heart-health/about/stories/in-action/cascades-east.html
March 01, 2021 - New Ideas Lead to Big Changes in Care
Like many small- and medium-sized practices, the team at Cascades East Family Medicine is always searching for ways to improve care. For Cascades East, this meant enrolling in EvidenceNOW, which connected them with a practice facilitator, Mr. Steven Brantley.
In their wor…
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psnet.ahrq.gov/node/48163/psn-pdf
July 31, 2019 - The MedSafer Study: a controlled trial of an electronic
decision support tool for deprescribing in acute care.
July 31, 2019
McDonald EG, Wu PE, Rashidi B, et al. The MedSafer Study: A Controlled Trial of an Electronic Decision
Support Tool for Deprescribing in Acute Care. J Am Geriatr Soc. 2019;67(9):1843-1850.
d…
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psnet.ahrq.gov/node/45914/psn-pdf
March 20, 2018 - Understanding the multidimensional effects of resident
duty hours restrictions: a thematic analysis of published
viewpoints in surgery.
March 20, 2018
Devitt KS, Kim MJ, Conn LG, et al. Understanding the Multidimensional Effects of Resident Duty Hours
Restrictions: A Thematic Analysis of Published Viewpoints in Su…
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psnet.ahrq.gov/node/46981/psn-pdf
May 04, 2019 - Lessons learned from implementing a principled
approach to resolution following patient harm.
May 4, 2019
Smith KM, Smith LL, (Jack) Gentry JC, et al. Lessons learned from implementing a principled approach to
resolution following patient harm. J Patient Saf Risk Manag. 2018;24(2):83-89.
doi:10.1177/25160435188138…
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psnet.ahrq.gov/node/42419/psn-pdf
July 17, 2013 - Health IT Patient Safety Action and Surveillance Plan.
July 17, 2013
Washington, DC: Office of the National Coordinator for Health Information Technology; July 2, 2013.
https://psnet.ahrq.gov/issue/health-it-patient-safety-action-and-surveillance-plan
This report from the Department of Health and Human Services (HH…
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psnet.ahrq.gov/node/45700/psn-pdf
September 01, 2018 - Resolving malpractice claims after tort reform: experience
in a self-insured Texas public academic health system.
September 1, 2018
Sage WM, Harding MC, Thomas EJ. Resolving Malpractice Claims after Tort Reform: Experience in a Self-
Insured Texas Public Academic Health System. Health Serv Res. 2016;51 Suppl 3:2615…
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psnet.ahrq.gov/node/42832/psn-pdf
September 01, 2016 - Overrides of medication-related clinical decision support
alerts in outpatients.
September 1, 2016
Nanji KC, Slight SP, Seger DL, et al. Overrides of medication-related clinical decision support alerts in
outpatients. J Am Med Inform Assoc. 2014;21(3):487-91. doi:10.1136/amiajnl-2013-001813.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45175/psn-pdf
February 22, 2017 - Improving physician's hand over among oncology staff
using standardized communication tool.
February 22, 2017
Alolayan A, Alkaiyat M, Ali Y, et al. Improving physician's hand over among oncology staff using
standardized communication tool. BMJ Qual Improv Rep. 2017;6(1).
doi:10.1136/bmjquality.u211844.w6141.
http…
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psnet.ahrq.gov/node/867041/psn-pdf
October 30, 2024 - "What else could it be?" A scoping review of questions
for patients to ask throughout the diagnostic process.
October 30, 2024
Hill MA, Coppinger T, Sedig K, et al. "What else could it be?" A scoping review of questions for patients to
ask throughout the diagnostic process. J Patient Saf. 2024;20(8):529-534.
doi:1…
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psnet.ahrq.gov/node/42149/psn-pdf
December 23, 2016 - Medical device alarm safety in hospitals.
December 23, 2016
Medical device alarm safety in hospitals. Sentinel event alert. 2013;(50):1-3.
https://psnet.ahrq.gov/issue/medical-device-alarm-safety-hospitals
The cacophony of alarms in hospitals has led many health care providers to become desensitized to them,
a con…
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psnet.ahrq.gov/node/37849/psn-pdf
March 23, 2011 - The incidence and nature of in-hospital adverse events: a
systematic review.
March 23, 2011
de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse
events: a systematic review. Qual Saf Health Care. 2008;17(3):216-223. doi:10.1136/qshc.2007.023622.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/42484/psn-pdf
August 14, 2013 - Parent willingness to remind health care workers to
perform hand hygiene.
August 14, 2013
Buser GL, Fisher BT, Shea JA, et al. Parent willingness to remind health care workers to perform hand
hygiene. Am J Infect Control. 2013;41(6):492-6. doi:10.1016/j.ajic.2012.08.006.
https://psnet.ahrq.gov/issue/parent-willing…
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psnet.ahrq.gov/node/45458/psn-pdf
November 30, 2016 - Request for comments on the proposed measures and
2020 targets for the National Action Plan for Adverse Drug
Event Prevention: inpatient and outpatient measures for
reduction of adverse drug events from anticoagulants,
diabetes agents, and opioid analgesics.
November 30, 2016
Office of Disease Prevention and Heal…
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psnet.ahrq.gov/node/60540/psn-pdf
November 01, 2016 - Quality improvement initiatives lead to reduction in
nulliparous term singleton vertex cesarean delivery rate.
November 1, 2016
Vadnais MA, Hacker MR, Shah NT, et al. Quality improvement initiatives lead to reduction in nulliparous
term singleton vertex cesarean delivery rate. Jt Comm J Qual Patient Saf. 2016;43(2)…
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psnet.ahrq.gov/node/40841/psn-pdf
October 16, 2012 - How dangerous is a day in hospital?: A model of adverse
events and length of stay for medical inpatients.
October 16, 2012
Hauck K, Zhao X. How dangerous is a day in hospital? A model of adverse events and length of stay for
medical inpatients. Med Care. 2011;49(12):1068-75. doi:10.1097/MLR.0b013e31822efb09.
https…
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www.ahrq.gov/teamstepps-program/curriculum/communication/teach/mini.html
May 01, 2023 - Mini-Session Training Content
If you are teaching content from the Communication Module in an even shorter format, focus on one or two specific communication tools or an important communication concept that has been selected based on the needs of the participants. For this format, do the following:
Using th…
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psnet.ahrq.gov/node/35407/psn-pdf
September 11, 2009 - Liability reform should make patients safer: "Avoidable
classes of events" are a key improvement.
September 11, 2009
Bovbjerg RR, Tancredi LR. Liability reform should make patients safer: "avoidable classes of events" are a
key improvement. J Law Med Ethics. 2005;33(3):478-500.
https://psnet.ahrq.gov/issue/liabili…
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psnet.ahrq.gov/node/47893/psn-pdf
April 08, 2019 - Challenges with implementing the Centers for Disease
Control and Prevention opioid guideline: a consensus
panel report.
April 8, 2019
Kroenke K, Alford DP, Argoff C, et al. Challenges with Implementing the Centers for Disease Control and
Prevention Opioid Guideline: A Consensus Panel Report. Pain Med. 2019;20(4):7…
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www.ahrq.gov/ncepcr/communities/pbrn/registry/rural-oklahoma-network.html
October 04, 2016 - Rural Oklahoma Network
Status:
Active
Registered Date:
October 4, 2016
PBRN Acronym:
ROK-Net
PBRN Type:
Mixed Network (a combination of family medicine, internal medicine, pediatrics, nursing and/or other specialties)
Network Category:
Developing
City:
Tulsa
…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams-2.html
July 01, 2023 - Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety
The Patient-Clinician Dyad
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Table of Contents
Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety
Introduction
The Patien…