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psnet.ahrq.gov/issue/opioid-related-critical-care-resource-use-us-childrens-hospitals
June 10, 2020 - Study
Emerging Classic
Opioid-related critical care resource use in US children's hospitals.
Citation Text:
Kane JM, Colvin JD, Bartlett AH, et al. Opioid-Related Critical Care Resource Use in US Children's Hospitals. Pediatrics. 2018;141(4):e20173335. doi:10.15…
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psnet.ahrq.gov/issue/inadequacies-physical-examination-cause-medical-errors-and-adverse-events-collection
June 01, 1989 - Study
Classic
Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes.
Citation Text:
Verghese A, Charlton B, Kassirer JP, et al. Inadequacies of Physical Examination as a Cause of Medical Errors and Advers…
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psnet.ahrq.gov/issue/effects-brief-team-training-program-surgical-teams-nontechnical-skills-interrupted-time
December 08, 2021 - Study
Effects of a brief team training program on surgical teams' nontechnical skills: an interrupted time-series study.
Citation Text:
Gillespie BM, Harbeck EL, Kang E, et al. Effects of a brief team training program on surgical teams' nontechnical skills: an interrupted time-series stu…
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psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences
March 20, 2019 - Book/Report
Classic
Why Things Bite Back: Technology and the Revenge of Unintended Consequences.
Citation Text:
Why Things Bite Back: Technology and the Revenge of Unintended Consequences. Tenner E. New York, NY: Knopf; 1996. ISBN: 0679425632.
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psnet.ahrq.gov/issue/apotex-corp-issues-voluntary-nationwide-recall-enoxaparin-sodium-injection-usp-due
March 22, 2010 - Press Release/Announcement
Apotex Corp. issues voluntary nationwide recall of Enoxaparin Sodium Injection, USP due to mislabeling of syringe barrel measurement markings.
Citation Text:
Apotex Corp. issues voluntary nationwide recall of Enoxaparin Sodium Injection, USP due to mislabeling …
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digital.ahrq.gov/document-type/book-publication
January 01, 2023 - Book Publication
Effective usability engineering in healthcare: A vision of usable and safer healthcare IT.
Citation
Kushniruk A, Senathirajah Y, Borycki E. Effective usability engineering in healthcare: A vision of usable and safer healthcare IT. Stud Health Technol Inform. …
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psnet.ahrq.gov/issue/nurses-perception-medication-administration-errors-and-factors-associated-their-reporting
December 14, 2022 - Study
Nurses' perception of medication administration errors and factors associated with their reporting in the neonatal intensive care unit.
Citation Text:
Henry Basil J, Premakumar CM, Mhd Ali A, et al. Nurses’ perception of medication administration errors and factors associated with …
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psnet.ahrq.gov/issue/factors-associated-potentially-harmful-medication-prescribing-nursing-homes-scoping-review
September 27, 2016 - Review
Factors associated with potentially harmful medication prescribing in nursing homes: a scoping review.
Citation Text:
Lipori JP, Tu E, Shireman TI, et al. Factors associated with potentially harmful medication prescribing in nursing homes: a scoping review. J Am Med Dir Assoc. 202…
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psnet.ahrq.gov/issue/human-factors-intervention-hospital-evaluating-outcome-teamstepps-program-surgical-ward
November 03, 2021 - Study
A human factors intervention in a hospital--evaluating the outcome of a TeamSTEPPS program in a surgical ward.
Citation Text:
Aaberg OR, Hall-Lord ML, Husebø SIE, et al. A human factors intervention in a hospital - evaluating the outcome of a TeamSTEPPS program in a surgical ward. …
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psnet.ahrq.gov/issue/impact-medicares-nonpayment-program-hospital-acquired-conditions
December 21, 2014 - Review
Impact of Medicare's nonpayment program on hospital-acquired conditions.
Citation Text:
Thirukumaran CP, Glance LG, Temkin-Greener H, et al. Impact of Medicare's Nonpayment Program on Hospital-acquired Conditions. Med Care. 2017;55(5):447-455. doi:10.1097/MLR.0000000000000680.
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psnet.ahrq.gov/issue/adverse-events-women-giving-birth-labor-ward-retrospective-record-review-study
April 14, 2021 - Study
Adverse events in women giving birth in a labor ward: a retrospective record review study.
Citation Text:
Skoogh A, Hall-Lord ML, Bååth C, et al. Adverse events in women giving birth in a labor ward: a retrospective record review study. BMC Health Serv Res. 2021;21(1):1093. doi:10.…
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psnet.ahrq.gov/issue/box-ticking-black-box-evolution-operating-room-safety
October 29, 2017 - Commentary
From box ticking to the black box: the evolution of operating room safety.
Citation Text:
Goldenberg MG, Elterman D. From box ticking to the black box: the evolution of operating room safety. World J Urol. 2019;38(6):1369-1372. doi:10.1007/s00345-019-02886-5.
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psnet.ahrq.gov/issue/can-we-rely-patients-reports-adverse-events
December 29, 2014 - Study
Classic
Can we rely on patients' reports of adverse events?
Citation Text:
Zhu J, Stuver SO, Epstein AM, et al. Can we rely on patients' reports of adverse events? Med Care. 2011;49(10):948-55. doi:10.1097/MLR.0b013e31822047a8.
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Format…
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digital.ahrq.gov/sites/default/files/docs/page/Utah%204-VI.ppt
June 16, 2021 - Medication History Settings
Utah Health Information Network
Evaluation Method Summary
AHRQ 2006
Jan Root, Ph.D.
Assistant Executive Director
UHIN Pilot
Submitter Receiver Message Format
Hospital Providers (clinical messages)
Payers (claim attachments) Discharge summaries, etc. HL7, pdf
Clinics Hospitals (clinic…
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psnet.ahrq.gov/issue/economic-measurement-medical-errors
March 23, 2022 - Book/Report
The Economic Measurement of Medical Errors.
Citation Text:
The Economic Measurement of Medical Errors. Shreve J, van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. Schaumburg, IL: The Society of Actuaries; 2010.
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psnet.ahrq.gov/issue/correlation-between-neonatal-intensive-care-unit-safety-culture-and-quality-care
November 20, 2019 - Study
The correlation between neonatal intensive care unit safety culture and quality of care.
Citation Text:
Profit J, Sharek PJ, Cui X, et al. The Correlation Between Neonatal Intensive Care Unit Safety Culture and Quality of Care. J Patient Saf. 2020;16(4):e310-e316. doi:10.1097/PTS.0…
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psnet.ahrq.gov/issue/ambulatory-computerized-prescribing-and-preventable-adverse-drug-events
June 11, 2014 - Study
Ambulatory computerized prescribing and preventable adverse drug events.
Citation Text:
Overhage JM, Gandhi TK, Hope C, et al. Ambulatory Computerized Prescribing and Preventable Adverse Drug Events. J Patient Saf. 2016;12(2):69-74. doi:10.1097/PTS.0000000000000194.
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psnet.ahrq.gov/issue/prescribers-interactions-medication-alerts-point-prescribing-multi-method-situ-investigation
January 07, 2015 - Study
Prescribers' interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the human–computer interaction.
Citation Text:
Russ AL, Zillich AJ, McManus S, et al. Prescribers' interactions with medication alerts at the point of prescribin…
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psnet.ahrq.gov/issue/you-can-campaign-teamwork-training-patients-and-families-ambulatory-oncology
September 01, 2016 - Study
The You CAN campaign: teamwork training for patients and families in ambulatory oncology.
Citation Text:
Weingart SN, Simchowitz B, Eng TK, et al. The You CAN campaign: teamwork training for patients and families in ambulatory oncology. Jt Comm J Qual Patient Saf. 2009;35(2):63-71.…
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psnet.ahrq.gov/issue/are-language-barriers-associated-serious-medical-events-hospitalized-pediatric-patients
November 16, 2022 - Study
Classic
Are language barriers associated with serious medical events in hospitalized pediatric patients?
Citation Text:
Cohen AL. Are Language Barriers Associated With Serious Medical Events in Hospitalized Pediatric Patients? Pediatrics. 2005;116(3):575…