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psnet.ahrq.gov/node/74045/psn-pdf
November 03, 2021 - ‘They treat me like I’m old and stupid’: seniors decry
health providers’ age bias.
November 3, 2021
Graham J. Kaiser Health News. October 20, 2021.
https://psnet.ahrq.gov/issue/they-treat-me-im-old-and-stupid-seniors-decry-health-providers-age-bias
Implicit biases permeate decision making and can impede safe and e…
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psnet.ahrq.gov/node/47821/psn-pdf
May 22, 2019 - Patient Safety.
May 22, 2019
National Pharmacy Association; NPA.
https://psnet.ahrq.gov/issue/patient-safety-15
This website for independent community pharmacy owners across the United Kingdom features both free
and members-only guidance, reporting platforms, and document templates to support patient safety. It
i…
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psnet.ahrq.gov/node/47884/psn-pdf
May 22, 2019 - Implementation and evaluation of a laboratory safety
process improvement toolkit.
May 22, 2019
Kwan BM, Fernald D, Ferrarone P, et al. Implementation and Evaluation of a Laboratory Safety Process
Improvement Toolkit. J Am Board Fam Med. 2019;32(2):136-145. doi:10.3122/jabfm.2019.02.180109.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/837710/psn-pdf
July 20, 2022 - Independent Neurology Inquiry.
July 20, 2022
Lockhart B, Mascie-Taylor H. Crown Copyright: London, England; June 2022. ISBN
9781912313631.
https://psnet.ahrq.gov/issue/independent-neurology-inquiry
Misdiagnosis of neurological conditions, such as stroke, can lead to delays in treatment and patient
morbidity…
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psnet.ahrq.gov/node/47696/psn-pdf
February 22, 2019 - Operating room fires.
February 22, 2019
Jones TS, Black IH, Robinson TN, et al. Operating Room Fires. Anesthesiology. 2019;130(3):492-501.
doi:10.1097/ALN.0000000000002598.
https://psnet.ahrq.gov/issue/operating-room-fires
Surgical fires, though uncommon, can result in serious harm. This review highlights three co…
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psnet.ahrq.gov/node/36785/psn-pdf
March 04, 2011 - Do professional interpreters improve clinical care for
patients with limited English proficiency? A systematic
review of the literature.
March 4, 2011
Karliner LS, Jacobs EA, Chen AH, et al. Do professional interpreters improve clinical care for patients with
limited English proficiency? A systematic review of the…
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psnet.ahrq.gov/node/47056/psn-pdf
April 20, 2022 - Healthcare Simulation Week.
April 20, 2022
Society for Simulation in Healthcare.
https://psnet.ahrq.gov/issue/healthcare-simulation-week
Simulation provides a safe space to observe behaviors and generate constructive feedback to enhance
individual and team performance. This website provides promotional materials f…
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psnet.ahrq.gov/node/43621/psn-pdf
October 22, 2014 - Multidisciplinary in-hospital teams improve patient
outcomes: a review.
October 22, 2014
Epstein NE. Multidisciplinary in-hospital teams improve patient outcomes: A review. Surg Neurol Int.
2014;5(Suppl 7):S295-303. doi:10.4103/2152-7806.139612.
https://psnet.ahrq.gov/issue/multidisciplinary-hospital-teams-improve…
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psnet.ahrq.gov/node/46557/psn-pdf
November 22, 2017 - Safe handover.
November 22, 2017
Merten H, van Galen LS, Wagner C. Safe handover. BMJ. 2017;359:j4328. doi:10.1136/bmj.j4328.
https://psnet.ahrq.gov/issue/safe-handover
Patient handovers between clinical teams are a common point of information exchange that can be
challenging to perform due to interruptions, produ…
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psnet.ahrq.gov/node/34882/psn-pdf
February 28, 2011 - Fumbled handoffs: one dropped ball after another.
February 28, 2011
Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med. 2005;142(5):352-358.
https://psnet.ahrq.gov/issue/fumbled-handoffs-one-dropped-ball-after-another
This case study discusses the chain of events surrounding the delayed dia…
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psnet.ahrq.gov/node/837076/psn-pdf
May 11, 2022 - AHRQ Challenge on Innovative Solutions To Update or
Re-Create TeamSTEPPS Videos.
May 11, 2022
Rockville, MD; Agency for Healthcare Research and Quality: April 2022.
https://psnet.ahrq.gov/issue/ahrq-challenge-innovative-solutions-update-or-re-create-teamstepps-videos
TeamSTEPPS promotes effective teamwork, collabo…
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psnet.ahrq.gov/node/60587/psn-pdf
June 10, 2020 - Person-Centered Guidelines for Preserving Family
Presence in Challenging Times.
June 10, 2020
Derby, CT: Planetree; 2020.
https://psnet.ahrq.gov/issue/person-centered-guidelines-preserving-family-presence-challenging-times
Families have an important role in keeping patients safe. This book provides a set of patien…
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psnet.ahrq.gov/node/44700/psn-pdf
March 23, 2016 - Factors that drive team participation in surgical safety
checks: a prospective study.
March 23, 2016
Gillespie BM, Withers TK, Lavin J, et al. Factors that drive team participation in surgical safety checks: a
prospective study. Patient Saf Surg. 2016;10:3. doi:10.1186/s13037-015-0090-5.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/47533/psn-pdf
June 19, 2019 - Patient Safety: A Health Affairs Briefing.
June 19, 2019
Project Hope.
https://psnet.ahrq.gov/issue/patient-safety-health-affairs-briefing
To Err Is Human was released almost 2 decades ago and continues to influence a growing area of study
aimed at improving health care and reducing medical error. This in-person a…
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www.ahrq.gov/antibiotic-use/long-term-care/improve/discuss-concerns.html
June 01, 2021 - Discussing Infectious Concerns About Residents
Effective communication may help residents and family members requesting antibiotics understand that there are potential risks associated with antibiotic use. Try using the DESC technique when conflicts develop with residents and/or their family members. Other po…
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psnet.ahrq.gov/node/41307/psn-pdf
May 04, 2012 - Development and validation of a tool to assess
emergency physicians' nontechnical skills.
May 4, 2012
Flowerdew L, Brown R, Vincent CA, et al. Development and validation of a tool to assess emergency
physicians' nontechnical skills. Ann Emerg Med. 2012;59(5):376-385.e4.
doi:10.1016/j.annemergmed.2011.11.022.
http…
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psnet.ahrq.gov/node/37393/psn-pdf
June 13, 2011 - Clinical information transfer and medication
reconciliation in patients transferred from the pediatric
intensive care unit.
June 13, 2011
Grant MJC, Larsen GY. Clinical Information Transfer and Medication Reconciliation in Patients Transferred
from the Pediatric Intensive Care Unit. J Patient Saf. 2008;3(4). doi:1…
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digital.ahrq.gov/ahrq-funded-projects/value-imaging-related-information-technology/final-report
January 01, 2023 - Value of Imaging-Related Information Technology - Final Report
Citation
Gazelle GS. Value of Imaging-Related Information Technology - Final Report. (Prepared by Massachusetts General Hospital under Grant No. R01 HS014891). Rockville, MD: Agency for Healthcare Research and Quality, 2008.
PDF
…
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digital.ahrq.gov/ahrq-funded-projects/incorporating-health-information-technology-workflow-redesign/citation/workflow
January 01, 2023 - Incorporating health information technology into workflow redesign: request for information summary report.
Citation
Carayon P, Karsh BT, Cartmill R, et al. Incorporating health information technology into workflow redesign: request for information summary report. Rockville, MD: Agency for Healthcare …
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digital.ahrq.gov/location/usa-md-college-park
January 01, 2023 - USA, MD, College Park
Annual Conference on Health Information Technology & Analytics (CHITA)
Description
The 2018-2020 annual Conference on Health IT & Analytics connected a wide range of academic disciplines, Federal agencies, policymakers, funders, practitioners, patient adv…