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  1. psnet.ahrq.gov/issue/when-things-go-wrong-how-health-care-organizations-deal-major-failures
    March 13, 2013 - View more articles from the same authors. … The authors analyzed case studies of serious, longstanding failures in healthcare delivery—such as the … The authors call for improvements in reporting and investigation mechanisms, and greater transparency
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34696/psn-pdf
    June 23, 2015 - https://psnet.ahrq.gov/issue/piece-my-mind-coping-fallibility The authors relate personal experiences … The authors argue for increased discussion of errors among physicians, both as an educational exercise … The authors suggest physician leaders in an organization can improve organizational culture by setting
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34719/psn-pdf
    December 23, 2008 - The authors cite examples of rare events and outline the strategies that organizations use to learn … The authors review two strategies for learning from rare events: one that focuses on experiencing the … The authors assess the reliability and validity of these approaches.
  4. cds.ahrq.gov/sites/default/files/CDS_Connect_2024_Final_Report.pdf
    January 01, 2024 - Experienced authors may also import externally authored CQL, specify run-time parameters, and test their … accomplishments include: • Adding a step-by-step tutorial to introduce the Authoring Tool to new authors … increasing CQL capabilities • Utilizing updated VSAC FHIR Application Programming Interface to provide authors … Software guidance • Introducing artifact metadata fields to encourage CDS developers and artifact authors … to promote the platform’s capabilities • Developing methods and mechanisms for providing artifact authors
  5. effectivehealthcare-admin.ahrq.gov/about/webinars
    January 01, 2025 - Center (SRC) of the EPC Program and AcademyHealth, these meetings feature presentations from EPC report authors … The authors of the reports, Julie Waldfogel, Pharm.D., BCGP, CPE, Jesse Wagner, M.A., and Bradford Winters … The authors of the reports, Roger Chou, M.D., FACP, M. … The authors of the two reports, Ian Saldanha M.B.B.S., M.P.H., Ph.D., and Dale Steele M.D., M.S., respectively … The authors of the two reports, Elham Hatef, M.D., and Annette Totten, Ph.D., respectively, shared the
  6. digital.ahrq.gov/health-it-tools-and-resources/health-it-costs-and-benefits-database/clinical-value-computerized
    May 01, 1996 - A review of 98 randomized clinical trials Authors:  Balas EA, Austin SM, Mitchell JA, Ewigman … Clinical Outcomes:  o Changes in healthcare utilization: The authors report the percent of HIT implementation … , Outpatient care, return and follow-up visits 64% Quality of Care and Patient Safety Outcome:  The authors … psychological measures reported beneficial effects of the HIT implementation Changes in healthcare costs:  The authors
  7. effectivehealthcare.ahrq.gov/sites/default/files/pdf/hepatic-fibrosis_white-paper.pdf
    April 01, 2014 - Research White Paper Impact of Contacting Study Authors on Systematic Review Conclusions: Diagnostic … to authors of older studies. … If still unable to reach corresponding authors, we attempted to contact last authors and statisticians … If corresponding authors forwarded our request to other authors, we sent reminders to these authors … Sample of Letter Sent to Authors
  8. effectivehealthcare-admin.ahrq.gov/sites/default/files/pdf/hepatic-fibrosis_white-paper.pdf
    April 01, 2014 - Research White Paper Impact of Contacting Study Authors on Systematic Review Conclusions: Diagnostic … to authors of older studies. … If still unable to reach corresponding authors, we attempted to contact last authors and statisticians … If corresponding authors forwarded our request to other authors, we sent reminders to these authors … Sample of Letter Sent to Authors
  9. effectivehealthcare.ahrq.gov/sites/default/files/pdf/transparency-mental-health_research-protocol.pdf
    September 01, 2016 - To achieve this goal, we will reach out to authors to understand the utility of clinicaltrials.gov and … (b) For studies with differences in reporting by source, we will reach out to study authors via email … (c) For completed and unpublished studies, we will reach out to authors of discontinued studies via … [For authors of included clinical trials included in the report that are clinical trials who have a … [For authors of studies included in the report that are NOT clinical trials, N=44, 11, 16, 17] 1.
  10. effectivehealthcare-admin.ahrq.gov/sites/default/files/pdf/transparency-mental-health_research-protocol.pdf
    September 01, 2016 - To achieve this goal, we will reach out to authors to understand the utility of clinicaltrials.gov and … (b) For studies with differences in reporting by source, we will reach out to study authors via email … (c) For completed and unpublished studies, we will reach out to authors of discontinued studies via … [For authors of included clinical trials included in the report that are clinical trials who have a … [For authors of studies included in the report that are NOT clinical trials, N=44, 11, 16, 17] 1.
  11. psnet.ahrq.gov/issue/market-based-control-mechanisms-patient-safety
    June 30, 2010 - View more articles from the same authors. … The authors discuss the design of a patient safety "market," measuring and putting a price on safety … While pointing out the challenges and barriers involved, the authors describe how market forces can be
  12. psnet.ahrq.gov/issue/how-surgeons-disclose-medical-errors-patients-study-using-standardized-patients
    July 10, 2008 - View more articles from the same authors. … The authors conclude that significant gaps exist between how physicians disclose medical errors and what … The same authors previously wrote a commentary calling for professional action in disclosure of medical
  13. psnet.ahrq.gov/issue/analysis-major-errors-and-equipment-failures-anesthesia-management-considerations-prevention
    May 27, 2011 - View more articles from the same authors. … The authors describe characteristics from more than 1000 incidents collected and offer strategies to … The authors conclude that it may be beneficial to classify specific incidents by a preventive strategy
  14. psnet.ahrq.gov/issue/communicating-patients-about-medical-errors-review-literature
    December 23, 2008 - View more articles from the same authors. … The authors found empirical support that the act of disclosure to patients doesn't consistently occur … practical guidance exists as to the nuts and bolts of who, what, when, and how to disclose, which the authors
  15. psnet.ahrq.gov/issue/what-causes-prescribing-errors-children-scoping-review
    September 09, 2015 - View more articles from the same authors. … The authors suggest that further research is needed to better understand how these factors are tied to … 14, 2020 How to prevent or reduce prescribing errors: an evidence brief for policy authors
  16. psnet.ahrq.gov/issue/maximizing-use-state-adverse-event-data-improve-patient-safety
    November 29, 2009 - View more articles from the same authors. … The authors present key findings and emphasize that the quality improvement aspect of reporting systems … Although the authors encourage greater use of reporting systems, a need exists for states to produce
  17. psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards
    March 03, 2011 - View more articles from the same authors. … The authors begin by presenting a conceptual framework of sensemaking before discussing both retrospective … The authors conclude that identifying risks to patient safety represents a critical step in prevention
  18. psnet.ahrq.gov/issue/operating-room-teamwork-among-physicians-and-nurses-teamwork-eye-beholder
    September 28, 2010 - View more articles from the same authors. … As teamwork remains a critical component of patient safety, the authors propose that a better understanding … The same authors recently described using the SAQ as a tool to evaluate safety culture in surgical
  19. psnet.ahrq.gov/issue/how-house-officers-cope-their-mistakes
    June 26, 2015 - View more articles from the same authors. … In this article, the authors report on how house officers cope with their medical mistakes and how different … The authors conclude with suggestions for medical educators to help residents handle serious medical
  20. psnet.ahrq.gov/issue/medication-errors-involving-wrong-administration-technique
    January 05, 2017 - View more articles from the same authors. … The authors discuss the severity of errors captured and their location of origin, in addition to the … The authors conclude with a series of recommendations focused on greater training in administration techniques