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  1. Psn-Pdf (pdf file)

    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.…
  2. Psn-Pdf (pdf file)

    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-…
  3. Psn-Pdf (pdf file)

    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 …
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. 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
  16. 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 …
  17. 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…
  18. #14 SUBSTANCE ABUSE (pdf file)

    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.…
  19. 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…
  20. 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…