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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - SPOTLIGHT CASE
What Happened on Telemetry?
Citation Text:
Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/issue/leveraging-consistent-communication-tools-and-organizational-values-promote-accountability
January 18, 2023 - Commentary
Leveraging consistent communication tools and organizational values to promote accountability among health care providers.
Citation Text:
Baldwin CA, Krumm AM. Leveraging consistent communication tools and organizational values to promote accountability among health care provi…
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psnet.ahrq.gov/issue/strategies-improving-communication-emergency-department-mediums-and-messages-noisy
November 17, 2010 - Commentary
Strategies for improving communication in the emergency department: mediums and messages in a noisy environment.
Citation Text:
Welch SJ, Cheung DS, Apker J, et al. Strategies for improving communication in the emergency department: mediums and messages in a noisy environ…
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psnet.ahrq.gov/issue/building-comprehensive-strategies-obstetric-safety-simulation-drills-and-communication
May 08, 2019 - Commentary
Building comprehensive strategies for obstetric safety: simulation drills and communication.
Citation Text:
Austin N, Goldhaber-Fiebert SN, Daniels K, et al. Building Comprehensive Strategies for Obstetric Safety: Simulation Drills and Communication. Anesth Analg. 2016;123(5):…
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psnet.ahrq.gov/issue/achieving-climate-patient-safety-focusing-relationships
December 19, 2017 - Study
Achieving a climate for patient safety by focusing on relationships.
Citation Text:
Manojlovich M, Kerr M, Davies B, et al. Achieving a climate for patient safety by focusing on relationships. Int J Qual Health Care. 2014;26(6):579-84. doi:10.1093/intqhc/mzu068.
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psnet.ahrq.gov/issue/disclosing-errors-patients-perspectives-registered-nurses
February 17, 2011 - Study
Disclosing errors to patients: perspectives of registered nurses.
Citation Text:
Shannon SE, Foglia MB, Hardy M, et al. Disclosing errors to patients: perspectives of registered nurses. Jt Comm J Qual Patient Saf. 2009;35(1):5-12.
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psnet.ahrq.gov/issue/fda-safety-communication-flexible-bronchoscopes-and-updated-recommendations-reprocessing
March 11, 2015 - Press Release/Announcement
FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing.
Citation Text:
FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. Silver Springs, MD: US Food and Drug Administration: Jun…
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psnet.ahrq.gov/issue/taking-challenge-improve-name-and-role-recognition-operating-room
July 12, 2023 - Review
Taking up the challenge to improve name and role recognition in the operating room.
Citation Text:
Thota B, Rabinowitz A, Guttman OT. Taking up the challenge to improve name and role recognition in the operating room. J Patient Saf. 2024;20(1):45-47. doi:10.1097/pts.00000000000011…
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psnet.ahrq.gov/issue/communication-outcomes-critical-imaging-results-computerized-notification-system
April 04, 2011 - Study
Communication outcomes of critical imaging results in a computerized notification system.
Citation Text:
Singh H, Arora HS, Vij MS, et al. Communication outcomes of critical imaging results in a computerized notification system. J Am Med Inform Assoc. 2007;14(4):459-66.
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psnet.ahrq.gov/issue/advancing-more-health-literate-approach-patient-safety
May 31, 2017 - Journal Article
Advancing a More Health-Literate Approach to Patient Safety
Citation Text:
Sanders LM. Advancing a More Health-Literate Approach to Patient Safety. J Pediatr. 2019;214:10-11. doi:10.1016/j.jpeds.2019.07.003.
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psnet.ahrq.gov/issue/unprofessional-behavior-leads-complications
October 31, 2023 - Audiovisual Presentation
Unprofessional Behavior Leads to Complications.
Citation Text:
Unprofessional Behavior Leads to Complications. JN Learning. 2020.
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psnet.ahrq.gov/issue/leading-clinical-handover-improvement-change-strategy-implement-best-practices-acute-care
May 18, 2022 - Commentary
Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting.
Citation Text:
Clarke CM, Persaud DD. Leading Clinical Handover Improvement. J Patient Saf. 2011;7(1):11-18. doi:10.1097/pts.0b013e31820c98a8.
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psnet.ahrq.gov/issue/using-ora-explore-relationship-nursing-unit-communication-patient-safety-and-quality-outcomes
December 11, 2008 - Study
Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes.
Citation Text:
Effken JA, Carley KM, Gephart SM, et al. Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes. Int J Me…
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psnet.ahrq.gov/issue/tangible-handoff-team-approach-advancing-structured-communication-labor-and-delivery
June 12, 2013 - Commentary
The tangible handoff: a team approach for advancing structured communication in labor and delivery.
Citation Text:
Block M, Ehrenworth JF, Cuce VM, et al. The tangible handoff: a team approach for advancing structured communication in labor and delivery. Jt Comm J Qual Patient…
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psnet.ahrq.gov/issue/kadcyla-ado-trastuzumab-emtansine-drug-safety-communication-potential-medication-errors
October 09, 2013 - Press Release/Announcement
Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion.
Citation Text:
Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion. …
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psnet.ahrq.gov/issue/disruptive-behavior-and-clinical-outcomes-perceptions-nurses-and-physicians
September 28, 2010 - Study
Classic
Disruptive behavior and clinical outcomes: perceptions of nurses and physicians.
Citation Text:
Rosenstein AH, O'Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. Am J Nurs. 2005;105(1):54-64; quiz 64-5.
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psnet.ahrq.gov/issue/making-it-easier-do-right-thing-modern-communication-qi-agenda
January 20, 2016 - Commentary
Making it easier to do the right thing: a modern communication QI agenda.
Citation Text:
Wynia M. Making it easier to do the right thing: a modern communication QI agenda. Patient Educ Couns. 2012;88(3):364-6. doi:10.1016/j.pec.2012.06.027.
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psnet.ahrq.gov/issue/delivering-truth-challenges-and-opportunities-error-disclosure-obstetrics
December 01, 2021 - Commentary
Delivering the truth: challenges and opportunities for error disclosure in obstetrics.
Citation Text:
Carranza L, Lyerly AD, Lipira L, et al. Delivering the Truth. Obstetrics & Gynecology. 2014;123(3). doi:10.1097/aog.0000000000000130.
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www.ahrq.gov/news/newsroom/case-studies/201526.html
January 01, 2018 - Iowa’s Waverly Health Center Uses AHRQ Tools to Improve Patient Safety
Search All Impact Case Studies
September 2015
Waverly Health Center, a critical access hospital in Waverly, Iowa, has used three AHRQ resources to improve communication, teamwork, and leadership engagement as part of ongoing efforts to i…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/pagliari-c-et-al-2004
January 01, 2004 - Pagliari C et al. 2004 "Electronic Clinical Communications Implementation (ECCI) in Scotland: a mixed-methods programme evaluation."
Reference
Pagliari C, Gilmour M, Sullivan F. Electronic Clinical Communications Implementation (ECCI) in Scotland: a mixed-methods programme evaluation. J Eval Clin Prac…