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2721. Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting. | PSNet
      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. Copy Citation …

2722. Using ORA to explore the relationship of nursing unit communication to patient safety and quality outcomes. | PSNet
      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…

2723. The tangible handoff: a team approach for advancing structured communication in labor and delivery. | PSNet
      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…

2724. Cognitive processes involved in blame and blame-like judgments and in forgiveness and forgiveness-like judgments. | PSNet
      psnet.ahrq.gov/issue/cognitive-processes-involved-blame-and-blame-judgments-and-forgiveness-and-forgiveness
      August 23, 2017 - Study Cognitive processes involved in blame and blame-like judgments and in forgiveness and forgiveness-like judgments. Citation Text: Mullet E, Rivière S, Sastre MTM. Cognitive processes involved in blame and blame-like judgments and in forgiveness and forgiveness-like judgments. Am J…

2725. Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences. | PSNet
      psnet.ahrq.gov/issue/communicating-pathology-and-laboratory-errors-anatomic-pathologists-and-laboratory-medical
      May 18, 2022 - Study Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences. Citation Text: Dintzis SM, Stetsenko GY, Sitlani CM, et al. Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medi…

2726. Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion. | PSNet
      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. …

2727. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. | PSNet
      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. …

2728. Making it easier to do the right thing: a modern communication QI agenda. | PSNet
      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. Copy Citation Format: …

2729. Shedding light on the dark side of doctor–patient interactions: verbal and nonverbal messages physicians communicate during error disclosures. | PSNet
      psnet.ahrq.gov/issue/shedding-light-dark-side-doctor-patient-interactions-verbal-and-nonverbal-messages-physicians
      June 14, 2017 - Study Shedding light on the dark side of doctor–patient interactions: verbal and nonverbal messages physicians communicate during error disclosures. Citation Text: Hannawa AF. Shedding light on the dark side of doctor-patient interactions: verbal and nonverbal messages physicians commu…

2730. Delivering the truth: challenges and opportunities for error disclosure in obstetrics. | PSNet
      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. Copy Citation Format: DOI…

2731. Iowa’s Waverly Health Center Uses AHRQ Tools to Improve Patient Safety | Agency for Healthcare Research and Quality
      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…

2732. Disclosing medical errors: prioritising the needs of patients and families. | PSNet
      psnet.ahrq.gov/issue/disclosing-medical-errors-prioritising-needs-patients-and-families
      November 11, 2020 - Commentary Disclosing medical errors: prioritising the needs of patients and families. Citation Text: Gallagher TH, Hemmelgarn C, Benjamin EM. Disclosing medical errors: prioritising the needs of patients and families. BMJ Qual Saf. 2023;32(10):557-561. doi:10.1136/bmjqs-2022-015880. C…

2733. The Medical Home Index: Revised Short Form: Pediatric. Measuring the Organization and Delivery of Pediatric Primary Care for All Children, Youth, and Families (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/mhi-rsf.pdf
      June 02, 2025 - In addition to Level 1, specialty referrals use phone, written and/or electronic communications; the

2734. Shared Medical Records and Chronic Illness Care | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/shared-medical-records-and-chronic-illness-care
      January 01, 2023 - Shared Medical Records and Chronic Illness Care Project Final Report ( PDF , 237.74 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No st…

2735. Additional Videos for TeamSTEPPS 3.0 | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/resources/additional/index.html
      September 01, 2023 - Additional Videos for TeamSTEPPS 3.0 Of the full list of videos below, the following videos are new with TeamSTEPPS 3.0 and have facilitator's guides to enable discussion of the video: Applying CUS and Teach Back in Inpatient Setting CUS for Maternal Health Equity Debrief in Emergency Department Hud…

2736. 2022 Updated Results for the AHRQ Surveys on Patient Safety CultureTM (SOPS®) Diagnostic Safety Supplemental Items for Medical Offices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/DxSftyRpt-Updated-2022.pdf
      January 01, 2022 - This finding indicates room for improvement in communications with nonprovider staff on these items,

2737. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet
      psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
      August 01, 2009 - Misplaced Nasogastric Tube Resulting in Aspiration Citation Text: Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google S…

2738. Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-about-cusp-slides.html
      July 01, 2023 - Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety AHRQ Safety Program for Perinatal Care Slide 1: AHRQ Safety Program for Perinatal Care Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety Slide 2: CUSP and Perinatal Safety Image: A chart is shown …

2739. Ambulatory Surgery Center Survey on Patient Safety Pilot Study Results (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc_pilotstudy.pdf
      April 01, 2015 - Ambulatory Surgery Center Survey on Patient Safety Pilot Study Results Results From the 2014 AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture Pilot Study Prepared for: Agency for Healthcare Research and Quality (AHRQ) U.S. Department of Health and Human Services (HHS) 540 Gaithe…

2740. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60952/psn-pdf
      September 30, 2020 - While multidisciplinary rounds will often facilitate this communication, more frequent brief communications