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121. Patterns of communication breakdowns resulting in injury to surgical patients. | PSNet
     psnet.ahrq.gov/issue/patterns-communication-breakdowns-resulting-injury-surgical-patients
     March 03, 2011 - View more articles from the same authors. … The authors analyzed more than 80 communication breakdowns identified in a past review of surgical … Based on the findings, the authors developed a series of triggers that would prompt a direct communication … In addition, the authors advocate for greater use of structured protocols to address handoffs and

122. Transparency of Reporting Requirements: Strategies to Improve Mental Health Care for Children and Adolescents | Effective Health Care (EHC) Program
     effectivehealthcare-admin.ahrq.gov/products/transparency-mental-health/research-protocol
     January 01, 2019 - To achieve this goal, we will reach out to authors to understand the utility of clinicaltrials.gov and … For studies with differences in reporting by source, we will reach out to study authors via email and … For completed and unpublished studies, we will reach out to authors of discontinued studies via email … Questions for authors of studies identified for the SIMHC report or through clinicaltrials.gov … For authors of included clinical trials included in the report that do not have a clinicaltrials.gov

123. Costs and benefits of picture archiving and communication systems | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency
     digital.ahrq.gov/health-it-tools-and-resources/health-it-costs-and-benefits-database/costs-and-benefits-picture
     August 02, 2021 - Costs and benefits of picture archiving and communication systems Authors:  Becker SH, Arenson … and indirect costs of PACSs, benefits of PACSs Summary: Settings:  Hospitals Evaluation Method:  The authors … The authors discussed several explanations for the differences. … Benefits:  The authors cited a few studies to suggest that PACSs will affect physician behaviors, patient

124. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34690/psn-pdf
     February 10, 2011 - https://psnet.ahrq.gov/issue/systems-analysis-adverse-drug-events The authors report a "systems analysis … Using 11 intensive and general care units at the two hospitals, the authors prospectively identified … The authors report their analysis of the underlying, or "system," causes of the ADEs as distinct from … Overall, the authors describe 16 system failures leading to ADEs, with seven accounting for 78% of all … Using the airline industry as an example, the authors advocate a nonpunitive systems approach as a more

125. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. | PSNet
     psnet.ahrq.gov/issue/estimating-hospital-deaths-due-medical-errors-preventability-eye-reviewer
     February 24, 2011 - View more articles from the same authors. … The authors attempt to address the concern that the estimates of deaths related to medical errors are … The authors retrospectively reviewed medical records of in-hospital deaths. … In their analysis, the authors report that clinicians estimated that only 0.5% of patients who died would

126. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73449/psn-pdf
     June 30, 2021 - Using a large commercial insurance claims database, the authors compared opioid prescribing patterns … The authors estimate a 14% increased risk for an opioid-related adverse outcome within one year when … The authors discuss how systematic differences in how pediatric and adult patients may be treated can

127. Aligning the Implementation of Ambulatory Care Surveys | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/news-and-events/newsitem14.html
     March 01, 2016 - Recognizing the challenges posed by multiple requirements for patient experience survey results, the authors … Specifically, the authors call on major stakeholders and survey users to reduce the burden of surveying

128. Standards and Regulatory Frameworks Workgroup: Charter – Option Year 2 (pdf file)
     cdsic.ahrq.gov/sites/default/files/2024-12/OY2_Final%20SRF%20Workgroup%20Charter.pdf
     January 01, 2024 - The opinions expressed in this document are those of the authors and do not reflect the official position … Following International Committee of Medical Journal Editors (ICJME) guidelines, authors must be able … Authorship order will be discussed collectively as a group with the authors. … • The co-authors will be listed in order of contribution to the conception, drafting, and review … • Each manuscript will have AHRQ co-authors.

129. National Patient Safety Foundation agenda for research and development in patient safety. | PSNet
     psnet.ahrq.gov/issue/national-patient-safety-foundation-agenda-research-and-development-patient-safety
     June 16, 2011 - View more articles from the same authors. … The authors begin this article by providing background on patient safety issues, a definition of patient … The authors emphasize the need to address issues along the continuum of patient safety, including epidemiology … The authors conclude that the ultimate test will be to determine whether NPSF programs have an impact

130. Transcranial Doppler Ultrasonography (TCD) Screening Among Children with Sickle Cell Anemia Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/pqmp/implementation-qi/toolkit/tcd/index.html
     September 01, 2021 - Specifically, the authors thank the patient and family members of the Sickle Cell Disease Trailblazers … The authors are solely responsible for this document’s contents, findings, and conclusions, which do … None of the authors has any affiliation or financial involvement that conflicts with the material presented

131. Safety Ethics: Cases from Aviation, Healthcare and Occupational and Environmental Health. | PSNet
     psnet.ahrq.gov/issue/safety-ethics-cases-aviation-healthcare-and-occupational-and-environmental-health
     August 02, 2016 - View more articles from the same authors. … The authors review the ethical foundations of safety in the aviation, health care, and occupational and … The authors encourage professionals to embrace ethical decision making in supporting their safety work

132. Supplemental Project To Assess the Transparency of Reporting for Strategies To Improve Mental Health Care for Children and Adolescents | Effective Health Care (EHC) Program
     effectivehealthcare.ahrq.gov/products/transparency-mental-health/research
     January 06, 2017 - KQ 3 For discontinued studies, we planned to reach out to authors via email to identify reasons for … Questions for authors of studies identified for the SIMHC report or through clinicaltrials.gov Authors … In clinicaltrials.gov, the authors provide raw data rather than adjusted results. … Authors who attempt to register studies on their own reported difficulties. … Second, authors did not generally report findings on clinicaltrials.gov.

133. OY2 Innovation Center Operational Framework (pdf file)
     cdsic.ahrq.gov/sites/default/files/2024-12/OY2%20Innovation%20Center%20Operational%20Framework_508.pdf
     January 01, 2024 - The opinions expressed in this document are those of the authors and do not reflect the official position … Following International Committee of Medical Journal Editors (ICJME) guidelines,0F1 authors must be … ■ The co-authors will be listed in order of contribution to the conception, drafting, and review of … ■ Each manuscript will have AHRQ co-authors. … Defining the Role of Authors and Contributors.

134. Interdisciplinary teamwork | PSNet
     psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
     April 28, 2025 - In this narrative review, the authors contrast approaches to teamwork in healthcare with current concepts … The authors encourage moving past a ‘reductionist’ ... … The authors review a series of... … However, methodological limitations of included studies precluded the authors from drawing conclusions … The authors share how a single adverse event catalyzed 7 years of efforts to bring patient safety to

135. When policy meets physiology: the challenge of reducing resident work hours. | PSNet
     psnet.ahrq.gov/issue/when-policy-meets-physiology-challenge-reducing-resident-work-hours
     January 10, 2017 - View more articles from the same authors. … Balancing these seemingly competing interests, the authors present an evidenced-based review of existing … The authors reference several commentaries that debate the work hour issues and call for greater attention … A widely referenced past study by one of the same authors, Dr.

136. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. | PSNet
     psnet.ahrq.gov/issue/squire-20-standards-quality-improvement-reporting-excellence-revised-publication-guidelines
     December 02, 2015 - View more articles from the same authors. … Since its introduction in 2008, authors and journal editors have widely adopted these guidelines to standardize … process that included semistructured interviews, focus groups, consensus meetings, pilot testing with authors … usability of the guidelines and omits the multiple sub-items that were felt to be too confusing for authors

137. Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error. | PSNet
     psnet.ahrq.gov/issue/turning-medical-gaze-upon-itself-root-cause-analysis-and-investigation-clinical-error
     June 14, 2011 - View more articles from the same authors. … The authors explain the contextual factors driving a commitment to quality and safety as a platform to … This discussion is illustrated with actual excerpts from an RCA, after which the authors analyze the … The authors suggest the need to address challenges in conducting RCAs but also raise the question of

138. Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors. | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency
     digital.ahrq.gov/health-it-tools-and-resources/health-it-bibliography/computerized-provider-order-entry-cpoe-systems
     July 12, 2021 - Netherlands, and Australia, using similar qualitative methods to investigate implementing PCISs, the authors … The authors describe the kinds of silent errors they have witnessed and, from their disciplines (information … The authors believe that with a heightened awareness of these issues, informaticians can educate, design

139. Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview. | PSNet
     psnet.ahrq.gov/issue/nurses-perceptions-and-experiences-communication-operating-theatre-focus-group-interview
     June 22, 2009 - View more articles from the same authors. … The authors interviewed nurses and found that conflict over perceived role contributed to ineffective … The authors posit that nurses' dissatisfaction with communication should be further explored for its

140. Editorial. Methods Guide for Authors of Systematic Reviews of Medical Tests: A Collaboration Between the Agency for Healthcare Research and Quality (AHRQ) and the Journal of General Internal Medicine | Effective Health Care (EHC) Program
     effectivehealthcare.ahrq.gov/products/methods-guide-editorial
     June 01, 2012 - Methods Guide for Authors of Systematic Reviews of Medical Tests: A Collaboration Between the Agency … Methods Guide for Authors of Systematic Reviews of Medical Tests: A Collaboration Between the Agency