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psnet.ahrq.gov/issue/death-suicide-within-1-week-hospital-discharge-retrospective-study-root-cause-analysis
May 04, 2022 - Study
Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports.
Citation Text:
Riblet N, Shiner B, Watts B, et al. Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports. J Nerv Ment Dis…
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psnet.ahrq.gov/issue/effective-interventions-and-implementation-strategies-reduce-adverse-drug-events-veterans
January 02, 2017 - Study
Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system.
Citation Text:
Mills PD, Neily J, Kinney LM, et al. Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs…
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psnet.ahrq.gov/issue/learning-environments-reliability-enhancing-work-practices-employee-engagement-and-safety
August 12, 2020 - Study
Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories.
Citation Text:
Gilmartin HM, Hess E, Mueller C, et al. Learning environments, reliability enhancing work practices, employee engagement, …
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psnet.ahrq.gov/issue/association-primary-care-clinic-appointment-time-opioid-prescribing
September 01, 2021 - Study
Association of primary care clinic appointment time with opioid prescribing.
Citation Text:
Neprash HT, Barnett ML. Association of Primary Care Clinic Appointment Time With Opioid Prescribing. JAMA Netw Open. 2019;2(8):e1910373. doi:10.1001/jamanetworkopen.2019.10373.
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psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys
January 17, 2012 - Study
Classic
Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system.
Citation Text:
DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the V…
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psnet.ahrq.gov/issue/prospective-evaluation-multifaceted-intervention-improve-outcomes-intensive-care-promoting
August 03, 2022 - Study
Classic
Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study.
Citation Text:
Dykes PC, Rozenblum R, Dalal A, et a…
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digital.ahrq.gov/care-setting/hospital
January 01, 2023 - Hospital
Bedside Notes: A Multicenter Trial to Improve Family Clinical Note Access and Outcomes for Hospitalized Children
Description
This research will evaluate the effectiveness of Bedside Notes, a digital health solution designed to provide caregivers with real-time access …
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psnet.ahrq.gov/issue/exploring-situational-awareness-diagnostic-errors-primary-care
September 20, 2011 - Study
Exploring situational awareness in diagnostic errors in primary care.
Citation Text:
Singh H, Giardina TD, Petersen LA, et al. Exploring situational awareness in diagnostic errors in primary care. BMJ Qual Saf. 2011;21(1):30-38. doi:10.1136/bmjqs-2011-000310.
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psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
October 24, 2018 - Study
Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.
Citation Text:
Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health A…
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psnet.ahrq.gov/issue/tempos-management-primary-care-key-factor-classifying-adverse-events-and-improving-quality
March 15, 2017 - Study
'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety.
Citation Text:
Amalberti R, Brami J. 'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety. BMJ Qual Saf.…
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digital.ahrq.gov/ahrq-funded-projects/using-health-information-technology-practice-redesign-impact-health-information-technology-on-workflow-nc
January 01, 2023 - Using Health Information Technology in Practice Redesign: Impact of Health Information Technology on Workflow
Project Final Report ( PDF , 2.07 MB)
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Project Description
Annual Summaries
Publications
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psnet.ahrq.gov/issue/predictive-power-trigger-tool-detection-adverse-events-general-surgery-multicenter
September 13, 2023 - Study
Predictive power of the "trigger tool" for the detection of adverse events in general surgery: a multicenter observational validation study.
Citation Text:
Pérez Zapata AI, Rodríguez Cuéllar E, de la Fuente Bartolomé M, et al. Predictive power of the "Trigger Tool" for the detectio…
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psnet.ahrq.gov/issue/operating-room-intensive-care-unit-handoffs-and-risks-patient-harm
October 05, 2022 - Study
Operating room to intensive care unit handoffs and the risks of patient harm.
Citation Text:
McElroy LM, Collins KM, Koller FL, et al. Operating room to intensive care unit handoffs and the risks of patient harm. Surgery. 2015;158(3):588-594. doi:10.1016/j.surg.2015.03.061.
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psnet.ahrq.gov/issue/so-many-ways-be-wrong-completeness-and-accuracy-prospective-study-or-icu-handoff
April 28, 2021 - Study
So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization.
Citation Text:
Conn Busch J, Wu J, Anglade E, et al. So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization. Jt …
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digital.ahrq.gov/ahrq-funded-projects/improving-quality-pediatric-emergency-care-using-electronic-medical-records/annual-summary/2011
January 01, 2011 - Improving the Quality of Pediatric Emergency Care Using an Electronic Medical Records - 2011
Project Name
Improving the Quality of Pediatric Emergency Care Using an Electronic Medical Record Registry and Clinician Feedback
Principal Investigator
Alpern, Elizabeth
Organization
…
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digital.ahrq.gov/ahrq-funded-projects/electronic-medication-management/annual-summary/2010
January 01, 2010 - Electronic Medication Management - 2010
Project Name
Electronic Medication Management
Principal Investigator
Vawdrey, David Kent
Organization
Columbia University
Funding Mechanism
PAR: HS08-268: Small Research Grant to Improve Health Care Quality Through Health Info…
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psnet.ahrq.gov/issue/covid-19-crisis-safe-reopening-simulation-centres-and-new-normal-food-thought
September 30, 2020 - Commentary
COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought.
Citation Text:
Ingrassia PL, Capogna G, Diaz-Navarro C, et al. COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought. Adv Simul (Lond). 2020;5:13. d…
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psnet.ahrq.gov/issue/occupational-therapy-utilization-veterans-dementia-retrospective-review-root-cause-analyses
March 25, 2020 - Study
Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading to adverse events.
Citation Text:
Rhodus EK, Lancaster EA, Hunter EG, et al. Occupational therapy utilization in veterans with dementia: a retrospective review…
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psnet.ahrq.gov/issue/patient-record-review-incidence-consequences-and-causes-diagnostic-adverse-events
July 02, 2014 - Study
Patient record review of the incidence, consequences, and causes of diagnostic adverse events.
Citation Text:
Zwaan L, de Bruijne M, Wagner C, et al. Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Arch Intern Med. 2010;170(12):1015-21…
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psnet.ahrq.gov/issue/design-and-impact-novel-surgery-specific-second-victim-peer-support-program
March 09, 2022 - Study
Emerging Classic
Design and impact of a novel surgery-specific second victim peer support program.
Citation Text:
El Hechi MW, Bohnen JD, Westfal M, et al. Design and Impact of a Novel Surgery-Specific Second Victim Peer Support Program. J Am Coll Surg. 2…