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psnet.ahrq.gov/node/37858/psn-pdf
June 25, 2008 - Measuring team performance in healthcare: review of
research and implications for patient safety.
June 25, 2008
Jeffcott SA, Mackenzie CF. Measuring team performance in healthcare: review of research and
implications for patient safety. J Crit Care. 2008;23(2):188-96. doi:10.1016/j.jcrc.2007.12.005.
https://psnet.…
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psnet.ahrq.gov/node/36041/psn-pdf
June 21, 2006 - Intraoperative adverse events and related postoperative
complications in spine surgery: implications for
enhancing patient safety founded on evidence-based
protocols.
June 21, 2006
Rampersaud YR; Moro ER; Neary MA; White K; Lewis SJ; Massicotte EM; Fehlings MG.
https://psnet.ahrq.gov/issue/intraoperative-adverse-…
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psnet.ahrq.gov/node/47354/psn-pdf
November 21, 2018 - Improving Diagnosis in Medicine Change Package.
November 21, 2018
Chicago, IL: Health Research & Educational Trust; 2018.
https://psnet.ahrq.gov/issue/improving-diagnosis-medicine-change-package
Proactive identification of conditions that degrade the diagnostic process can drive improvement. This
toolkit provides …
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psnet.ahrq.gov/node/38701/psn-pdf
June 28, 2011 - Selection of indicators for continuous monitoring of
patient safety: recommendations of the project 'safety
improvement for patients in Europe.'
June 28, 2011
Kristensen S, Mainz J, Bartels P. Selection of indicators for continuous monitoring of patient safety:
recommendations of the project 'safety improvement f…
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psnet.ahrq.gov/node/60563/psn-pdf
June 03, 2020 - ‘Last responders’ seek to expand postmortem COVID
testing In unexplained deaths.
June 3, 2020
Andrews M. Kaiser News Network. May 19, 2020.
https://psnet.ahrq.gov/issue/last-responders-seek-expand-postmortem-covid-testing-unexplained-deaths
Post-mortem examination is an important tool for determining if misdiagnos…
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psnet.ahrq.gov/node/866357/psn-pdf
July 24, 2024 - People’s Experiences of Diagnosis.
July 24, 2024
People’s Experiences Of Diagnosis. London, England: National Voices; June 2024.
https://psnet.ahrq.gov/issue/peoples-experiences-diagnosis
The discussion of diagnostic safety has expanded to include an effort to realize excellence. This report
explores the diagnosti…
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psnet.ahrq.gov/node/836867/psn-pdf
April 06, 2022 - Safer Dx Checklist: 10 High-Priority Practices for
Diagnostic Excellence.
April 6, 2022
Houston TX; Baylor College of Medicine: 2022.
https://psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence
Assessment can identify the current state of a process or program to reveal ar…
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psnet.ahrq.gov/node/73451/psn-pdf
June 30, 2021 - National Patient Safety Syllabus.
June 30, 2021
Spurgeon P, Cross S. London, UK; Academy of Medical Royal Colleges: May 2021.
https://psnet.ahrq.gov/issue/national-patient-safety-syllabus
Amending curricula to incorporate the increasing scholarship related to patient safety improvement is a
challenge. This st…
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psnet.ahrq.gov/node/34719/psn-pdf
December 23, 2008 - Learning from samples of one or fewer.
December 23, 2008
March JG, Sproull LS, Tamuz M. Org Sci.1991;2:1-13. (reprinted in: Qual Saf Health Care 2003;12:465-
472.)
https://psnet.ahrq.gov/issue/learning-samples-one-or-fewer
Organizations learn from experience. However, learning from rare events is challenging becau…
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psnet.ahrq.gov/node/37564/psn-pdf
June 12, 2008 - The medical emergency team system: a two hospital
comparison.
June 12, 2008
Young L, Donald M, Parr M, et al. The Medical Emergency Team system: a two hospital comparison.
Resuscitation. 2008;77(2):180-8. doi:10.1016/j.resuscitation.2007.11.016.
https://psnet.ahrq.gov/issue/medical-emergency-team-system-two-hospit…
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psnet.ahrq.gov/node/37086/psn-pdf
October 03, 2011 - Failure mode and effects analysis: a useful tool for risk
identification and injury prevention.
October 3, 2011
Paparella S. Failure mode and effects analysis: a useful tool for risk identification and injury prevention.
Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Ass…
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psnet.ahrq.gov/node/36622/psn-pdf
January 14, 2011 - Measuring errors in surgical pathology in real-life
practice: defining what does and does not matter.
January 14, 2011
Renshaw AA, Gould EW. Measuring errors in surgical pathology in real-life practice: defining what does
and does not matter. Am J Clin Pathol. 2007;127(1):144-52.
https://psnet.ahrq.gov/issue/measu…
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psnet.ahrq.gov/node/34887/psn-pdf
February 26, 2009 - Has the Leapfrog Group had an impact on the health care
market?
February 26, 2009
Galvin RS, Delbanco S, Milstein A, et al. Has the leapfrog group had an impact on the health care market?
Health Aff (Millwood). 2005;24(1):228-33.
https://psnet.ahrq.gov/issue/has-leapfrog-group-had-impact-health-care-market
The Le…
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psnet.ahrq.gov/node/43375/psn-pdf
July 23, 2014 - Managing risk at the point-of-care: preventing errors.
July 23, 2014
Njoroge S; Nichols JH.
https://psnet.ahrq.gov/issue/managing-risk-point-care-preventing-errors
Highlighting how the disconnect between clinicians conducting point-of-care testing as a patient care action
and laboratory staff performing the analys…
-
digital.ahrq.gov/sites/default/files/docs/citation/r18hs025943-snyder-final-report-2024.pdf
January 01, 2024 - Patient satisfaction was assessed using four items
answered by patients at the end of their PatientToc … Tailor to
Context: Promote
Adaptability
Not applicable (language needs
at each pharmacy were
assessed
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.pdf
April 01, 2011 - Strategy 4: IDEA Discharge Planning (Implementation Handbook)
Strategy 4: IDEAL Discharge Planning (Implementation Handbook)
Guide to Patient and Family Engagement
Care Transitions from
Hospital to Home:
IDEAL Discharge Planning
Implementation Handbook
Strategy 4: IDEAL Discharge Planning (Implementation …
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/dementia-nursing-home-characteristics_research-protocol.pdf
November 03, 2011 - Evidence-based Practice Center Systematic Review Protocol
Source: www.effectivehealthcare.ahrq.gov
Published Online: November 3, 2011
Evidence-based Practice Center Systematic Review Protocol
Project Title: Comparison of Characteristics of Nursing Homes and Other
Residential Long-Term Care Settings for Peo…
-
effectivehealthcare.ahrq.gov/sites/default/files/substance-abuse-horizon-scan-high-impact-1406.pdf
January 01, 2020 - #14 SUBSTANCE ABUSE
AHRQ Healthcare Horizon Scanning System – Potential
High-Impact Interventions Report
Priority Area 14: Substance Abuse
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
www.ahrq.…
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www.ahrq.gov/sites/default/files/2024-07/col-report.pdf
January 01, 2024 - Final Progress Report: Incorporating Temporary Health States into Decision Support
AHRQ Grant Final Progress Report
Title Page
Title of Project: Incorporating Temporary Health States into Decision Support
Final Report submitted by:
Maine Medical Center
22 Bramhall Street
Portland, ME 04102
Principal Investigator…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/asd-interventions-disposition.pdf
May 26, 2017 - Interventions Targeting Sensory Challenges in Children With Autism Spectrum Disorders - An Update
Comparative Effectiveness Review Disposition of Comments Report
Research Review Title: Interventions Targeting Sensory Challenges in Children With
Autism Spectrum Disorder (ASD)—An Update
Draft review ava…