-
psnet.ahrq.gov/node/862129/psn-pdf
February 07, 2024 - Application of "Human Factor Analysis and Classification
System" (HFACS) model to the prevention of medical
errors and adverse events: a systematic review.
February 7, 2024
Jalali M, Dehghan H, Habibi E, et al. Int J Prev Med. 2023;14:127.
https://psnet.ahrq.gov/issue/application-human-factor-analysis-and-classifi…
-
psnet.ahrq.gov/node/72502/psn-pdf
November 25, 2020 - Patient safety in primary care: conceptual meanings to
the health care team and patients.
November 25, 2020
Lai AY. Patient safety in primary care: conceptual meanings to the health care team and patients. J Am
Board Fam Med. 2020;33(5):754-764. doi:10.3122/jabfm.2020.05.200042.
https://psnet.ahrq.gov/issue/patien…
-
psnet.ahrq.gov/node/72600/psn-pdf
December 23, 2020 - Improving hospital safety culture for falls prevention
through interdisciplinary health education.
December 23, 2020
Lopez-Jeng C, Eberth SD. Improving hospital safety culture for falls prevention through interdisciplinary
health education. Health Promot Pract. 2020;21(6):918-925. doi:10.1177/1524839919840337.
htt…
-
psnet.ahrq.gov/node/47912/psn-pdf
April 24, 2019 - A systematic literature review and narrative synthesis on
the risks of medical discharge letters for patients' safety.
April 24, 2019
Schwarz CM, Hoffmann M, Schwarz P, et al. A systematic literature review and narrative synthesis on the
risks of medical discharge letters for patients' safety. BMC Health Serv Res. …
-
psnet.ahrq.gov/node/866958/psn-pdf
October 16, 2024 - Beyond error: a qualitative study of human factors in
serious adverse events.
October 16, 2024
Mujuru C, Peisah C. Beyond error: a qualitative study of human factors in serious adverse events. J
Healthc Risk Manag. 2024;44(2):7-13. doi:10.1002/jhrm.21583.
https://psnet.ahrq.gov/issue/beyond-error-qualitative-study…
-
psnet.ahrq.gov/node/866857/psn-pdf
October 02, 2024 - Reducing falls in hospitalized children and adolescents
with cancer and blood disorders: a quality improvement
journey.
October 2, 2024
Morrissey LK, Ho P, Ilowite M, et al. Reducing falls in hospitalized children and adolescents with cancer
and blood disorders: a quality improvement journey. Pediatr Qual Saf. 202…
-
psnet.ahrq.gov/node/44409/psn-pdf
January 22, 2016 - "Anybody on this list that you're more worried about?"
Qualitative analysis exploring the functions of questions
during end of shift handoffs.
January 22, 2016
O'Brien CM, Flanagan ME, Bergman AA, et al. "Anybody on this list that you're more worried about?"
Qualitative analysis exploring the functions of question…
-
psnet.ahrq.gov/node/39074/psn-pdf
November 04, 2009 - Development and usability of a behavioural marking
system for performance assessment of obstetrical teams.
November 4, 2009
Tregunno D, Pittini R, Haley M, et al. Development and usability of a behavioural marking system for
performance assessment of obstetrical teams. Qual Saf Health Care. 2009;18(5):393-6.
doi:1…
-
psnet.ahrq.gov/node/35838/psn-pdf
March 28, 2011 - Unscheduled returns to the emergency department: an
outcome of medical errors?
March 28, 2011
Nuñez S, Hexdall A, Aguirre-Jaime A. Unscheduled returns to the emergency department: an outcome of
medical errors? Qual Saf Health Care. 2006;15(2):102-8.
https://psnet.ahrq.gov/issue/unscheduled-returns-emergency-depart…
-
psnet.ahrq.gov/node/73316/psn-pdf
May 26, 2021 - Racial bias among emergency providers: strategies to
mitigate its adverse effects.
May 26, 2021
Brockett-Walker C, Lall M, Evans DD, et al. Racial bias among emergency providers: strategies to mitigate
its adverse effects. Adv Emerg Nurs J. 2021;43(2):89-101. doi:10.1097/tme.0000000000000352.
https://psnet.ahrq.go…
-
psnet.ahrq.gov/node/73388/psn-pdf
June 16, 2021 - Reducing surgical specimen errors through
multidisciplinary quality improvement.
June 16, 2021
Holstine JB, Samora JB. Reducing surgical specimen errors through multidisciplinary quality improvement.
Jt Comm J Qual Patient Saf. 2021;47(9):563-571. doi:10.1016/j.jcjq.2021.04.003.
https://psnet.ahrq.gov/issue/reduci…
-
psnet.ahrq.gov/node/46270/psn-pdf
April 16, 2018 - Impact of a restraint management bundle on restraint use
in an intensive care unit.
April 16, 2018
Hall DK, Zimbro KS, Maduro RS, et al. Impact of a Restraint Management Bundle on Restraint Use in an
Intensive Care Unit. J Nurs Care Qual. 2018;33(2):143-148. doi:10.1097/NCQ.0000000000000273.
https://psnet.ahrq.gov…
-
psnet.ahrq.gov/node/43942/psn-pdf
March 11, 2015 - FDA requires label warnings to prohibit sharing of multi-
dose diabetes pen devices among patients.
March 11, 2015
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 25, 2015.
https://psnet.ahrq.gov/issue/fda-requires-label-warnings-prohibit-sharing-multi-dose-diabetes-pen-device…
-
psnet.ahrq.gov/node/73491/psn-pdf
July 14, 2021 - Patient and family engagement in catheter-associated
urinary tract infection (CAUTI) prevention: a systematic
review.
July 14, 2021
Mangal S, Pho A, Arcia A, et al. Patient and family engagement in catheter-associated urinary tract
infection (CAUTI) prevention: a systematic review. Jt Comm J Qual Patient Saf. 2021…
-
psnet.ahrq.gov/node/41389/psn-pdf
June 27, 2012 - Can we make postoperative patient handovers safer? A
systematic review of the literature.
June 27, 2012
Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer? A
systematic review of the literature. Anesth Analg. 2012;115(1):102-15.
doi:10.1213/ANE.0b013e318253af4b.
https:/…
-
psnet.ahrq.gov/node/42084/psn-pdf
July 02, 2014 - Promoting a culture of safety as a patient safety strategy:
a systematic review.
July 2, 2014
Weaver SJ, Lubomksi LH, Wilson RF, et al. Promoting a culture of safety as a patient safety strategy: a
systematic review. Ann Intern Med. 2013;158(5 Pt 2):369-74. doi:10.7326/0003-4819-158-5-201303051-
00002.
https://ps…
-
psnet.ahrq.gov/node/60973/psn-pdf
September 30, 2020 - During the pandemic, aspire to identify and prevent
medication errors and to avoid blaming attitudes.
September 30, 2020
ISMP Medication Safety Alert! Acute care edition. August 27, 2020;25(17).
https://psnet.ahrq.gov/issue/during-pandemic-aspire-identify-and-prevent-medication-errors-and-avoid-
blaming-attitudes
…
-
digital.ahrq.gov/ahrq-funded-projects/privacy-and-security-solutions-interoperable-hie-ak
January 01, 2023 - Privacy and Security Solutions for Interoperable Health Information Exchange / Alaska
Project Description
Project Details -
Completed
Contract Number
290-05-0015-RTI-034
Funding Mechanism(s)
Health Information Security and Privacy Colla…
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T2-Sample_Procedures_Phase_3.doc
January 01, 1999 - Comprehensive Antibiogram Toolkit: Phase 3
Sample Procedures
[NURSING HOME NAME]
[DATE]
Purpose and Scope
This procedure covers the use of an antibiogram at [NURSING HOME NAME]. Antibiotics are among the most commonly prescribed pharmaceuticals in long-term-care settings, yet reports indicate that a high proportion …
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/addressing-emerging-needs-09132023-welcome.pdf
June 02, 2025 - AHRQ CAHPS Program: Addressing Emergining Needs for Patient Experience Measurement & Improvement webcast - WELCOME
AHRQ’s CAHPS Program: Addressing Emerging Needs
for Patient Experience Measurement and Improvement
A Webinar Presented by the AHRQ CAHPS User Network
Wednesday, September 13
12:00 – 1:00 pm ET
Webc…