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221. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34706/psn-pdf
     December 23, 2012 - psnet.ahrq.gov/issue/analysing-potential-harm-australian-general-practice-incident-monitoring-study The authors … The authors provide a detailed breakdown of the types of incidents, factors that mitigated the harm … The authors classify the underlying causes of the events in four categories—communications problems,

222. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34665/psn-pdf
     December 24, 2008 - The authors present existing research to illustrate the interplay between how an organization learns … The authors argue that true learning in health organizations occurs through a cyclical, dualistic, and … The authors discuss the barriers to effective learning and suggest that leadership must play an active

223. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866115/psn-pdf
     June 12, 2024 - The authors concluded that there is no consensus definition for polypharmacy. … The authors also identified considerable variability in the types of interventions used to address polypharmacy

224. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866808/psn-pdf
     September 25, 2024 - Transformational and transactional leadership formed the foundation for many definitions, though the authors … The authors propose that future research focus on the relationship between leadership style and safety

225. Computer based nursing documentation means to achieve the goal | 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/computer-based-nursing
     Computer based nursing documentation means to achieve the goal Authors:  Burkle T, Michel A … Cost of Implementation:  The authors report that no specific ICU software has been used nor have bedside … The authors report that up to 10% of the paper forms contained false TISS scores due to mathematical … The authors stated that the use of the electronic system provided more complete documentation due to

226. AHRQ Slide Template 2009 (ppt file)
     effectivehealthcare.ahrq.gov/sites/default/files/reporting.ppt
     September 01, 2009 - When authors do not provide sufficient details concerning the conduct of their study, readers are left … …Disagreements were resolved by discussion between the two review authors. … from the authors of the primary studies. … The example in the slide gives the level of detail that authors should report. … In the example in this slide, authors provide the rationale in a narrative format.

227. AHRQ Slide Template 2009 (ppt file)
     effectivehealthcare-admin.ahrq.gov/sites/default/files/reporting.ppt
     September 01, 2009 - When authors do not provide sufficient details concerning the conduct of their study, readers are left … …Disagreements were resolved by discussion between the two review authors. … from the authors of the primary studies. … The example in the slide gives the level of detail that authors should report. … In the example in this slide, authors provide the rationale in a narrative format.

228. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73415/psn-pdf
     June 23, 2021 - issue/patient-safety-dermatology-ten-year-update In an update to their 2010 article, this review’s authors … The authors recommend further studies, and reports are needed to reduce errors and improve patient safety

229. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-284
     March 15, 2021 - The authors recommend creating policies restricting nurse shifts to no more than 12 hours per day and … The authors analyzed 24 checklists used in 18 Swiss hospitals, identified major differences between study … The authors suggest that future research should explore ways to improve the quality of surgical timeouts … The authors examined contributors to error-associated deaths occurring between 1996-2004 and 2005-2014 … The authors suggest that incorporating HIE data into reimbursement programs could promote more accurate

230. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-276
     January 29, 2021 - The authors found little evidence describing the role of healthcare workers in reducing or amplifying … Leveraging lessons learned from the pandemic, the authors use a human factors perspective to propose … The authors recommend several strategies for reducing wrong-patient errors.  … Leveraging lessons learned from the pandemic, the authors use a human factors perspective to propose … The authors found little evidence describing the role of healthcare workers in reducing or amplifying

231. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36088/psn-pdf
     September 28, 2010 - The authors report that the stated behaviors affected communication, teamwork, staff relationships, … The authors conclude that organizations must acknowledge the presence and effect of disruptive behaviors … A past survey study by the same authors examined the impact of work relationships on clinical outcomes

232. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47843/psn-pdf
     March 06, 2019 - https://psnet.ahrq.gov/issue/structural-iatrogenesis-43-year-old-man-opioid-misuse The authors describe … The authors refer to this type of harm as "structural iatrogenesis."

233. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72819/psn-pdf
     March 10, 2021 - The authors present a generalizable approach for identifying patients at risk of being mis- or overdiagnosed … Using chronic obstructive pulmonary disease (COPD) patients as an example, the authors outline how to

234. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60815/psn-pdf
     August 19, 2020 - clinical-reasoning-wild-premature-closure-during-covid-19-pandemic In this Letter to the Editor, the authors … The authors discuss the potential implications through a clinical story involving a redeployed resident

235. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60592/psn-pdf
     June 17, 2020 - https://psnet.ahrq.gov/issue/african-american-covid-19-mortality-sentinel-event The authors of this … The authors propose several actions to mitigate the effects of the pandemic and work towards addressing

236. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-300
     July 28, 2021 - The authors suggest that improvements in an organization’s health and wellness support programs could … To expand resident understanding of and participation in RCA, the authors developed simulated RCAs that … The authors suggest that improvements in an organization’s health and wellness support programs could … In a review of how regulators influence safety culture in several high-reliability fields, the authors … Using an example of a smart infusion pump, the authors discuss how to apply this concept in healthcare

237. Stakeholder Community and Outreach Center: Operational Framework – Option Year 2 (pdf file)
     cdsic.ahrq.gov/sites/default/files/2024-12/OY2_Final%20Stakeholder%20Center%20Operational%20Framework.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. … Defining the Role of Authors and Contributors. … • Each manuscript will have AHRQ co-authors.

238. Impact of voice- and knowledge-enabled clinical reporting--US example | 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/impact-voice-and-knowledge
     January 01, 2002 - Impact of voice- and knowledge-enabled clinical reporting--US example Authors:  Bushko RG, … Implementation:  The authors introduced voice-enabled and guidelines-based clinical reporting and described … Changes in efficiency and productivity:  The authors estimated the cost-savings of the system by eliminating … The authors predicted that, if only 14 percent of all US physicians (100,000 physicians) adopted voice

239. Disposition of Comments for Progestogens for Prevention of Preterm Birth (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/related_files/progestogens-preterm-birth-disposition-121205.pdf
     September 07, 2012 - The authors may wish to modify the initial comment regarding “no maternal factors”. … However, the authors may not have had a way to know this. … The authors may also want to add “multiple gestation.” … The authors attempt to logically follow through the key questions. … The authors adequately summarize the data and arrive at clear recommendations.

240. Disposition of Comments for Progestogens for Prevention of Preterm Birth (pdf file)
     effectivehealthcare-admin.ahrq.gov/sites/default/files/related_files/progestogens-preterm-birth-disposition-121205.pdf
     September 07, 2012 - The authors may wish to modify the initial comment regarding “no maternal factors”. … However, the authors may not have had a way to know this. … The authors may also want to add “multiple gestation.” … The authors attempt to logically follow through the key questions. … The authors adequately summarize the data and arrive at clear recommendations.