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psnet.ahrq.gov/issue/rapid-response-teams-qualitative-analysis-their-effectiveness
November 02, 2010 - Study
Rapid response teams: qualitative analysis of their effectiveness.
Citation Text:
Leach LS, Mayo AM. Rapid response teams: qualitative analysis of their effectiveness. Am J Crit Care. 2013;22(3):198-210. doi:10.4037/ajcc2013990.
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psnet.ahrq.gov/issue/role-nursing-surveillance-keeping-patients-safe
July 14, 2009 - Commentary
The role of nursing surveillance in keeping patients safe.
Citation Text:
Dresser S. The role of nursing surveillance in keeping patients safe. J Nurs Adm. 2012;42(7-8):361-368. doi:10.1097/NNA.0b013e3182619377.
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psnet.ahrq.gov/issue/building-nursing-intellectual-capital-safe-use-information-technology-systematic-review
June 23, 2009 - Review
Building nursing intellectual capital for safe use of information technology: a systematic review.
Citation Text:
Poe SS. Building nursing intellectual capital for safe use of information technology: a systematic review. J Nurs Care Qual. 2011;26(1):4-12. doi:10.1097/NCQ.0b013e31…
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psnet.ahrq.gov/issue/evaluating-safety-and-competency-bedside
November 16, 2022 - Commentary
Evaluating safety and competency at the bedside.
Citation Text:
Kaplan T, Pilcher J. Evaluating safety and competency at the bedside. J Nurses Staff Dev. 2011;27(4):187-90. doi:10.1097/NND.0b013e3182236634.
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psnet.ahrq.gov/issue/identification-root-causes-emergency-diagnostic-imaging-delays-three-canadian-hospitals
July 02, 2014 - Study
Identification of root causes for emergency diagnostic imaging delays at three Canadian hospitals.
Citation Text:
Worster A, Fernandes CMB, Malcolmson C, et al. Identification of root causes for emergency diagnostic imaging delays at three Canadian hospitals. J Emerg Nurs. 2006;3…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-starting-practice.pdf
June 02, 2025 - Job Aid: Starting with a Practice
Primary Care Practice Facilitator
Training Series
1
Job Aid: Starting with a Practice
Overview
How you start with a practice can set the tone for your work with the practice. Do your
homework and be well prepared for all of your meetings. Spend time getting to know…
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psnet.ahrq.gov/issue/missed-steps-preanesthetic-set
June 26, 2019 - Study
Missed steps in the preanesthetic set-up.
Citation Text:
DeMaria S, Blasius K, Neustein SM. Missed steps in the preanesthetic set-up. Anesth Analg. 2011;113(1):84-8. doi:10.1213/ANE.0b013e318219645e.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-1.html
June 01, 2020 - Operational Measurement of Diagnostic Safety: State of the Science
Introduction
Previous Page Next Page
Table of Contents
Operational Measurement of Diagnostic Safety: State of the Science
Introduction
Special Considerations for Measurement of Diagnostic Safety
Getting Ready for Measurement: O…
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psnet.ahrq.gov/issue/new-graduate-registered-nurses-knowledge-patient-safety-and-practice-literature-review
June 13, 2018 - Review
New graduate registered nurses' knowledge of patient safety and practice: a literature review.
Citation Text:
Murray M, Sundin D, Cope V. New graduate registered nurses' knowledge of patient safety and practice: A literature review. J Clin Nurs. 2018;27(1-2):31-47. doi:10.1111/joc…
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psnet.ahrq.gov/issue/year-1-medical-undergraduates-knowledge-and-attitudes-medical-error
March 24, 2011 - Study
Year 1 medical undergraduates' knowledge of and attitudes to medical error.
Citation Text:
Flin R, Patey R, Jackson J, et al. Year 1 medical undergraduates' knowledge of and attitudes to medical error. Med Educ. 2009;43(12):1147-55. doi:10.1111/j.1365-2923.2009.03499.x.
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psnet.ahrq.gov/issue/learning-samples-one-or-fewer
December 21, 2017 - Review
Classic
Learning from samples of one or fewer.
Citation Text:
Learning from samples of one or fewer. March JG, Sproull LS, Tamuz M. Org Sci.1991;2:1-13. (reprinted in: Qual Saf Health Care 2003;12:465-472.)
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psnet.ahrq.gov/issue/nursephysician-communication-through-sensemaking-lens-shifting-paradigm-improve-patient
June 05, 2024 - Review
Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety.
Citation Text:
Manojlovich M. Nurse/physician communication through a sensemaking lens: shifting the paradigm to improve patient safety. Med Care. 2010;48(11):941-6. doi:10…
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www.ahrq.gov/talkingquality/translate/presentation.html
April 01, 2016 - Why Does the Presentation of Health Care Quality Scores Matter?
Most people have trouble understanding complex information.
Only a small fraction of Americans can easily read complex tables or understand the words typically used in medicine and health. The 2003 National Assessment of Adult Literacy found that…
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psnet.ahrq.gov/issue/quantification-anesthesia-providers-hand-hygiene-busy-metropolitan-operating-room-what-would
September 20, 2023 - Study
Quantification of anesthesia providers' hand hygiene in a busy metropolitan operating room: what would Semmelweis think?
Citation Text:
Biddle C, Shah J. Quantification of anesthesia providers' hand hygiene in a busy metropolitan operating room: what would Semmelweis think? Am J …
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www.ahrq.gov/gam/summaries/domain-framework/index.html
July 01, 2018 - NQMC Measure Domain Framework
The National Quality Measures Clearinghouse (NQMC) was a database of measures meeting specific criteria for inclusion. Measures in NQMC were classified into domains according to the domain framework below.
There are many dimensions of performance related to clinical health care d…
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psnet.ahrq.gov/issue/human-factors-anaesthetic-practice-insights-task-analysis
April 18, 2011 - Study
Human factors in anaesthetic practice: insights from a task analysis.
Citation Text:
Phipps D, Meakin GH, Beatty PCW, et al. Human factors in anaesthetic practice: insights from a task analysis. Br J Anaesth. 2008;100(3):333-43. doi:10.1093/bja/aem392.
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psnet.ahrq.gov/issue/eliminating-perioperative-adverse-events-ascension-health
November 16, 2022 - Commentary
Eliminating perioperative adverse events at Ascension Health.
Citation Text:
Ewing H, Bruder G, Baroco P, et al. Eliminating perioperative adverse events at Ascension Health. Jt Comm J Qual Patient Saf. 2007;33(5):256-66.
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psnet.ahrq.gov/issue/raising-and-responding-frontline-concerns-healthcare
November 13, 2019 - Commentary
Raising and responding to frontline concerns in healthcare.
Citation Text:
Mannion R, Davies H. Raising and responding to frontline concerns in healthcare. BMJ. 2019;366:l4944. doi:10.1136/bmj.l4944.
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psnet.ahrq.gov/issue/teams-psychologists-helping-teams-evolution-science-team-training
February 26, 2020 - Commentary
Emerging Classic
Teams of psychologists helping teams: the evolution of the science of team training.
Citation Text:
Bisbey TM, Reyes DL, Traylor AM, et al. Teams of psychologists helping teams: The evolution of the science of team training. Am Psycho…
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www.ahrq.gov/news/newsroom/case-studies/ktcquips82.html
October 01, 2014 - Five Nebraska Hospitals Use AHRQ Toolkit to Improve Medication Reconciliation Across Care Settings
Search All Impact Case Studies
November 2011
Between January and September 2010, AHRQ partnered with seven Quality Improvement Organizations (QIOs) to deliver a series of onsite learning sessions and provider …