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psnet.ahrq.gov/issue/effective-physician-nurse-communication-patient-safety-essential-labor-and-delivery
May 21, 2019 - Study
Effective physician–nurse communication: a patient safety essential for labor and delivery.
Citation Text:
Lyndon A, Zlatnik MG, Wachter R. Effective physician-nurse communication: a patient safety essential for labor and delivery. Am J Obstet Gynecol. 2011;205(2):91-6. doi:10.10…
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psnet.ahrq.gov/issue/approaches-decreasing-medication-and-other-care-errors-icu
September 30, 2010 - Review
Approaches to decreasing medication and other care errors in the ICU.
Citation Text:
Valentin A. Approaches to decreasing medication and other care errors in the ICU. Curr Opin Crit Care. 2013;19(5):474-9. doi:10.1097/MCC.0b013e328364d4f9.
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psnet.ahrq.gov/issue/impact-workplace-mistreatment-patient-safety-risk-and-nurse-assessed-patient-outcomes
September 24, 2010 - Study
Impact of workplace mistreatment on patient safety risk and nurse-assessed patient outcomes.
Citation Text:
Laschinger HKS. Impact of workplace mistreatment on patient safety risk and nurse-assessed patient outcomes. J Nurs Adm. 2014;44(5):284-90. doi:10.1097/NNA.0000000000000068. …
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psnet.ahrq.gov/issue/simulation-based-adverse-event-reporting-system-development-and-feasibility
July 08, 2020 - Study
Simulation based adverse event reporting system: development and feasibility.
Citation Text:
Mckay M, Sanko JS. Simulation Based Adverse Event Reporting System: Development and Feasibility. Clin Simul Nurs. 2014;10(5). doi:10.1016/j.ecns.2013.12.005.
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www.ahrq.gov/news/newsroom/case-studies/202502.html
February 01, 2025 - Kaiser Permanente School of Anesthesia Uses AHRQ’s Surveys on Patient Safety Culture®, TeamSTEPPS®
Search All Impact Case Studies
February 2025
Kaiser Permanente (KP) School of Anesthesia in Pasadena, California, uses AHRQ’s Surveys on Patient Safety Culture (SOPS®) to improve ambulatory care and expand d…
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psnet.ahrq.gov/issue/culture-safety-results-organization-wide-survey-15-california-hospitals
November 18, 2009 - Study
Classic
The culture of safety: results of an organization-wide survey in 15 California hospitals.
Citation Text:
Singer SJ, Gaba DM, Geppert JJ, et al. The culture of safety: results of an organization-wide survey in 15 California hospitals. Qual Saf Hea…
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psnet.ahrq.gov/issue/intolerance-error-and-culture-blame-drive-medical-excess
March 24, 2017 - Commentary
Intolerance of error and culture of blame drive medical excess.
Citation Text:
Hoffman JR, Kanzaria HK. Intolerance of error and culture of blame drive medical excess. BMJ. 2014;349(oct14 3). doi:10.1136/bmj.g5702.
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psnet.ahrq.gov/issue/diagnostic-stewardship-prevent-diagnostic-error
May 05, 2021 - Commentary
Diagnostic stewardship to prevent diagnostic error.
Citation Text:
Morgan DJ, Malani PN, Diekema DJ. Diagnostic stewardship to prevent diagnostic error. JAMA. 2023;329(15):1255-1256. doi:10.1001/jama.2023.1678.
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psnet.ahrq.gov/issue/apparent-cause-analysis-safety-tool
June 27, 2018 - Study
Apparent cause analysis: a safety tool.
Citation Text:
Parikh K, Hochberg E, Cheng JJ, et al. Apparent cause analysis: a safety tool. Pediatrics. 2020;145(5):e20191819. doi:10.1542/peds.2019-1819.
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www.ahrq.gov/news/blog/ahrqviews/burnout-in-primary-care-guide.html
April 01, 2023 - AHRQ Views: Blog posts from AHRQ leaders
New Guide Offers Strategies To Reduce Clinician Burdens
APR
24
2023
By
Robert Otto
Valdez,
Ph.D., M.H.S.A.
Robert Otto Valdez, Ph.D., M.H.S.A.
In recent years, primary care physicians have struggled with burnout brought on …
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psnet.ahrq.gov/issue/strategies-flipping-script-opioid-overprescribing
May 29, 2019 - Commentary
Strategies for flipping the script on opioid overprescribing.
Citation Text:
Wright AP, Becker WC, Schiff G. Strategies for Flipping the Script on Opioid Overprescribing. JAMA Intern Med. 2016;176(1):7-8. doi:10.1001/jamainternmed.2015.5946.
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psnet.ahrq.gov/issue/opioid-epidemic-what-can-surgeons-do-about-it
March 27, 2019 - Commentary
The opioid epidemic: what can surgeons do about it?
Citation Text:
The opioid epidemic: what can surgeons do about it? Saluja S, Selzer D, Meara JG, et al. Bull Am Coll Surg. 2017;102(7):13-18.
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psnet.ahrq.gov/issue/parenteral-opioid-shortage-treating-pain-during-opioid-overdose-epidemic
January 31, 2024 - Commentary
Emerging Classic
Parenteral opioid shortage—treating pain during the opioid-overdose epidemic.
Citation Text:
Bruera E. Parenteral Opioid Shortage - Treating Pain during the Opioid-Overdose Epidemic. N Engl J Med. 2018;379(7):601-603. doi:10.1056/NEJM…
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psnet.ahrq.gov/issue/disclosure-medical-errors-ethical-considerations-development-facility-policy-and
August 30, 2017 - Commentary
Disclosure of medical errors: ethical considerations for the development of a facility policy and organizational culture change.
Citation Text:
Henry LL. Disclosure of medical errors: ethical considerations for the development of a facility policy and organizational culture ch…
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psnet.ahrq.gov/issue/blinding-or-information-control-diagnosis-could-it-reduce-errors-clinical-decision-making
October 13, 2018 - Review
Blinding or information control in diagnosis: could it reduce errors in clinical decision-making?
Citation Text:
Lockhart JJ, Satya-Murti S. Blinding or information control in diagnosis: could it reduce errors in clinical decision-making? Diagnosis (Berl). 2018;5(4):179-189. doi:1…
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psnet.ahrq.gov/issue/impact-electronic-health-record-systems-information-integrity-quality-and-safety-implications
April 03, 2024 - Review
Impact of electronic health record systems on information integrity: quality and safety implications.
Citation Text:
Bowman S. Impact of electronic health record systems on information integrity: quality and safety implications. Perspect Health Inf Manag. 2013;10:1c.
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psnet.ahrq.gov/issue/relationship-between-patients-perceptions-team-effectiveness-and-their-care-experience
June 08, 2011 - Study
The relationship between patients' perceptions of team effectiveness and their care experience in the emergency department.
Citation Text:
Kipnis A, Rhodes K, Burchill CN, et al. The relationship between patients' perceptions of team effectiveness and their care experience in the…
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psnet.ahrq.gov/issue/chemotherapy-medication-errors
May 19, 2014 - Review
Emerging Classic
Chemotherapy medication errors.
Citation Text:
Weingart SN, Zhang L, Sweeney M, et al. Chemotherapy medication errors. Lancet Oncol. 2018;19(4):e191-e199. doi:10.1016/S1470-2045(18)30094-9.
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psnet.ahrq.gov/issue/patients-and-health-care-professionals-attitudes-towards-pink-patient-safety-video
December 16, 2013 - Study
Patients' and health care professionals' attitudes towards the PINK patient safety video.
Citation Text:
Davis R, Pinto A, Sevdalis N, et al. Patients' and health care professionals' attitudes towards the PINK patient safety video. J Eval Clin Pract. 2012;18(4):848-53. doi:10.111…
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psnet.ahrq.gov/issue/patients-attitudes-towards-patient-involvement-safety-interventions-results-two-exploratory
July 06, 2012 - Study
Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies.
Citation Text:
Davis R, Sevdalis N, Pinto A, et al. Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies. Health Exp…