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psnet.ahrq.gov/node/44552/psn-pdf
June 21, 2016 - Reducing diagnostic errors—why now?
June 21, 2016
Khullar D, Jha AK, Jena AB. Reducing diagnostic errors--why now? N Engl J Med. 2015;373(26):2491-
2493. doi:10.1056/NEJMp1508044.
https://psnet.ahrq.gov/issue/reducing-diagnostic-errors-why-now
Diagnostic error has recently garnered attention as a patient safety pr…
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psnet.ahrq.gov/node/35872/psn-pdf
September 07, 2011 - Improving ambulatory prescribing safety with a handheld
decision support system: a randomized controlled trial.
September 7, 2011
Berner ES, Houston TK, Ray MN, et al. Improving ambulatory prescribing safety with a handheld decision
support system: a randomized controlled trial. J Am Med Inform Assoc. 2006;13(2):17…
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psnet.ahrq.gov/node/44776/psn-pdf
April 15, 2016 - Best practices for chemotherapy administration in
pediatric oncology: quality and safety process
improvements (2015).
April 15, 2016
Looper K, Winchester K, Robinson D, et al. Best Practices for Chemotherapy Administration in Pediatric
Oncology: Quality and Safety Process Improvements (2015). J Pediatr Oncol Nurs.…
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psnet.ahrq.gov/node/50832/psn-pdf
January 01, 2021 - Preventing critical failure. Can routinely collected data be
repurposed to predict avoidable patient harm? A
quantitative descriptive study.
January 29, 2020
Nowotny BM, Davies-Tuck M, Scott B, et al. Preventing critical failure. Can routinely collected data be
repurposed to predict avoidable patient harm? A quant…
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psnet.ahrq.gov/node/863214/psn-pdf
February 28, 2024 - Appropriate use of medical interpreters in the breast
imaging clinic.
February 28, 2024
Feliciano-Rivera YZ, Yepes MM, Sanchez P, et al. Appropriate use of medical interpreters in the breast
imaging clinic. J Breast Imaging. 2024;27(3):296-303. doi:10.1093/jbi/wbad109.
https://psnet.ahrq.gov/issue/appropriate-use-…
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psnet.ahrq.gov/node/36154/psn-pdf
September 29, 2010 - Harmful medication errors in children: a 5-year analysis of
data from the USP's MEDMARX(R) program.
September 29, 2010
Hicks RW, Becker SC, Cousins DD. Harmful medication errors in children: a 5-year analysis of data from
the USP's MEDMARX program. J Pediatr Nurs. 2006;21(4):290-8.
https://psnet.ahrq.gov/issue/har…
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psnet.ahrq.gov/node/73137/psn-pdf
April 14, 2021 - Adverse drug event-related admissions to a pediatric
emergency unit.
April 14, 2021
Carvalho IV, Sousa VM de, Visacri MB, et al. Adverse drug event-related admissions to a pediatric
emergency unit. Pediatr Emerg Care. 2021;37(4):e152-e158. doi:10.1097/pec.0000000000001582.
https://psnet.ahrq.gov/issue/adverse-drug…
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psnet.ahrq.gov/node/47059/psn-pdf
May 16, 2018 - Participating in a multisite study exploring operational
failures encountered by frontline nurses: lessons learned.
May 16, 2018
Melnyk H, Rosenfeld P, Glassman KS. Participating in a Multisite Study Exploring Operational Failures
Encountered by Frontline Nurses: Lessons Learned. J Nurs Adm. 2018;48(4):203-208.
do…
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psnet.ahrq.gov/node/849317/psn-pdf
May 24, 2023 - Implementing an electronic root cause analysis reporting
system to decrease hospital-acquired pressure injuries.
May 24, 2023
Armstrong AA. Implementing an electronic root cause analysis reporting system to decrease hospital-
acquired pressure injuries. J Healthc Qual. 2023;45(3):125-132. doi:10.1097/jhq.0000000000…
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psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
April 01, 2008 - There are three primary critiques :
There is considerable interrater variability in determining … experienced clinical reviewers achieve only moderate agreement on whether or not an error even occurred, and determining
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/medical-evidence-communication_executive.pdf
November 01, 2013 - After
determining article inclusion, one reviewer entered data
about studies into evidence tables and … While this tactic creates the potential
for a more powerful effect, it also complicates determining … Key Points: Disseminating Evidence to Patients
• Evidence is inconsistent for determining the beneft … • Evidence is insuffcient for determining the beneft
of reach, ability, motivation, or multicomponent … • Evidence is insuffcient for determining the beneft
of reach, ability, motivation, or multicomponent
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-guidance-de-novo-processes_methods.pdf
September 01, 2009 - Determining How To Use Existing Systematic Reviews
At this point in the process, we assume that EPCs … These include:
• Determining whether the targeted SR search strategy that has been proposed
in this … • Determining whether it is more efficient to search for an SR as part of the
overall search strategy … • Determining specific criteria to assess the quality of individual patient data
meta-analyses. … • Determining if SRs evaluating diagnostic tests or harms require a different
emphasis on certain
-
effectivehealthcare.ahrq.gov/sites/default/files/systematicreviewsreplacedenovo.pdf
September 01, 2009 - Determining How To Use Existing Systematic Reviews
At this point in the process, we assume that EPCs … These include:
• Determining whether the targeted SR search strategy that has been proposed
in this … • Determining whether it is more efficient to search for an SR as part of the
overall search strategy … • Determining specific criteria to assess the quality of individual patient data
meta-analyses. … • Determining if SRs evaluating diagnostic tests or harms require a different
emphasis on certain
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psnet.ahrq.gov/issue/economic-evaluation-quality-improvement-interventions-prevent-catheter-associated-urinary
January 25, 2017 - May 11, 2022
Determining the skills needed by frontline NHS staff to deliver quality
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psnet.ahrq.gov/issue/managing-prevention-retained-surgical-instruments-what-value-counting
September 25, 2008 - June 8, 2016
Comparison of military and civilian methods for determining potentially
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psnet.ahrq.gov/issue/leveraging-redesigned-morbidity-and-mortality-conference-incorporates-clinical-and
April 24, 2018 - December 3, 2018
Comparison of military and civilian methods for determining potentially
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psnet.ahrq.gov/issue/potential-consequences-patient-complications-surgeon-well-being-systematic-review
May 23, 2018 - Related Resources From the Same Author(s)
Comparison of military and civilian methods for determining
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psnet.ahrq.gov/issue/cost-effectiveness-computerized-provider-order-entry-system-improving-medication-safety
August 09, 2017 - December 21, 2016
Comparison of military and civilian methods for determining potentially
-
digital.ahrq.gov/ahrq-funded-projects/impact-health-it-implementation-diabetes-process-and-outcome-measures/annual-summary/2011
January 01, 2011 - care, estimating the prevalence of voluntary physician use of the DMF embedded within the EHR, and determining
-
digital.ahrq.gov/ahrq-funded-projects/impact-health-it-implementation-diabetes-process-and-outcome-measures/annual-summary/2012
January 01, 2012 - also investigating the prevalence of voluntary physician use of the DMF embedded within the EHR, and determining