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psnet.ahrq.gov/node/34654/psn-pdf
June 16, 2011 - Risk mitigation in large scale systems: lessons from high
reliability organizations.
June 16, 2011
Grabowski M, Roberts K. Calif Manag Rev. 1997;39(4):152-161.
https://psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations
The authors examine high-reliability organizations,…
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psnet.ahrq.gov/node/43881/psn-pdf
February 11, 2015 - Cognitive Systems Engineering in Health Care.
February 11, 2015
Bisantz AM, Burns CM, Fairbanks RJ, eds. Boca Raton, FL: CRC Press; 2014. ISBN: 9781466587960.
https://psnet.ahrq.gov/issue/cognitive-systems-engineering-health-care
This publication provides information about the role of cognition in medical error. Th…
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psnet.ahrq.gov/node/861769/psn-pdf
January 31, 2024 - Psychological safety and hierarchy in operating room
debriefing: reflexive thematic analysis.
January 31, 2024
McElroy C, Skegg E, Mudgway M, et al. Psychological safety and hierarchy in operating room debriefing:
reflexive thematic analysis. J Surg Res. 2023;295:567-573. doi:10.1016/j.jss.2023.11.054.
https://psn…
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psnet.ahrq.gov/node/43213/psn-pdf
June 04, 2014 - Back to basics: preventing surgical site infections.
June 4, 2014
Spruce L. Back to basics: preventing surgical site infections. AORN J. 2014;99(5):600-8; quiz 609-11.
doi:10.1016/j.aorn.2014.02.002.
https://psnet.ahrq.gov/issue/back-basics-preventing-surgical-site-infections
Surgical site infections are a common …
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psnet.ahrq.gov/node/47181/psn-pdf
August 22, 2018 - Critical role of the surgeon–anesthesiologist relationship
for patient safety.
August 22, 2018
Cooper JB. Critical Role of the Surgeon-Anesthesiologist Relationship for Patient Safety. Anesthesiology.
2018;129(3):402-405. doi:10.1097/ALN.0000000000002324.
https://psnet.ahrq.gov/issue/critical-role-surgeon-anesthes…
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www.ahrq.gov/funding/process/index.html
March 01, 2016 - Grants Process and Application Basics
Grant application process guidance and application basics.
Grant Application Basics
Provides links to guides on how to create grant applications to AHRQ to supporting research to improve the quality, effectiveness, accessibility, and cost effectiveness of health c…
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psnet.ahrq.gov/node/44512/psn-pdf
September 23, 2015 - Increased mortality associated with weekend hospital
admission: a case for expanded seven day services?
September 23, 2015
Freemantle N, Ray D, McNulty D, et al. Increased mortality associated with weekend hospital admission: a
case for expanded seven day services? BMJ. 2015;351:h4596. doi:10.1136/bmj.h4596.
https…
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psnet.ahrq.gov/node/40770/psn-pdf
September 14, 2011 - 'August is always a nightmare': results of the Royal
College of Physicians of Edinburgh and Society of Acute
Medicine August transition survey.
September 14, 2011
Vaughan L, McAlister G, Bell D. 'August is always a nightmare': results of the Royal College of Physicians
of Edinburgh and Society of Acute Medicine Au…
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psnet.ahrq.gov/node/47771/psn-pdf
April 24, 2019 - The impact of errors on healthcare professionals in the
critical care setting.
April 24, 2019
Kaur AP, Levinson AT, Monteiro JFG, et al. The impact of errors on healthcare professionals in the critical
care setting. J Crit Care. 2019;52:16-21. doi:10.1016/j.jcrc.2019.03.001.
https://psnet.ahrq.gov/issue/impact-err…
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psnet.ahrq.gov/node/41763/psn-pdf
October 10, 2012 - Latency of ECG displays of hospital telemetry systems: a
science advisory from the American Heart Association.
October 10, 2012
Turakhia MP, Estes NAM, Drew BJ, et al. Latency of ECG displays of hospital telemetry systems: a science
advisory from the American Heart Association. Circulation. 2012;126(13):1665-9.
ht…
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www.uspreventiveservicestaskforce.org/uspstf/individualizing-cancer-screening-older-adults-figure-1
October 01, 2012 - Individualizing Cancer Screening in Older Adults - Figure 1
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Incorporating Considerations Important to Older Adults Into the USPSTF Screening Framework
The figure illustra…
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digital.ahrq.gov/ahrq-funded-projects/expansion-implementation-evaluation-electronic-health-record-integrated-patient/citation/protocol
January 01, 2023 - Protocol for a type 2 hybrid effectiveness-implementation study expanding, implementing and evaluating electronic health record-integrated patient-reported symptom monitoring in a multisite cancer centre.
Citation
Garcia SF, Smith JD, Kallen M, Webster KA, Lyleroehr M, Kircher S, Bass M, Cella D, Pene…
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psnet.ahrq.gov/node/844791/psn-pdf
September 18, 2019 - Review of alternatives to root cause analysis: developing
a robust system for incident report analysis.
September 18, 2019
Hagley G, Mills PD, Watts B, et al. Review of alternatives to root cause analysis: developing a robust
system for incident report analysis. BMJ Open Qual. 2019;8(3):e000646. doi:10.1136/bmjoq-2…
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psnet.ahrq.gov/node/47355/psn-pdf
September 05, 2018 - Preventing medication errors in the information age.
September 5, 2018
Godshall M, Riehl M. Preventing medication errors in the information age. Nursing (Brux). 2018;48(9):56-
58. doi:10.1097/01.NURSE.0000544230.51598.38.
https://psnet.ahrq.gov/issue/preventing-medication-errors-information-age
Failure to consider…
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www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-eval-roadmap/ccre-roadmap-ap.html
July 01, 2013 - Clinical-Community Relationships Evaluation Roadmap
Appendices: Preliminary Work and Finding
Previous Page Next Page
Table of Contents
Clinical-Community Relationships Evaluation Roadmap
Executive Summary
1. Introduction and Purpose
2. Priority Questions and Recommendations
3. Conclusion
R…
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psnet.ahrq.gov/node/38727/psn-pdf
November 25, 2009 - FMEA team performance in health care: a qualitative
analysis of team member perceptions.
November 25, 2009
Wetterneck TB, Hundt AS, Carayon P. FMEA Team Performance in Health Care. J Patient Saf. 2009;5(2).
doi:10.1097/pts.0b013e3181a852be.
https://psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative…
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psnet.ahrq.gov/node/47798/psn-pdf
February 20, 2019 - Simulation safety first: an imperative.
February 20, 2019
Raemer D, Hannenberg A, Mullen A. Simulation Safety First: An Imperative. Simul Healthc.
2018;13(6):373-375. doi:10.1097/SIH.0000000000000341.
https://psnet.ahrq.gov/issue/simulation-safety-first-imperative
Although simulation training heightens the learnin…
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psnet.ahrq.gov/node/855428/psn-pdf
November 15, 2023 - A study of error reporting by nurses: the significant
impact of nursing team dynamics.
November 15, 2023
Munn LT, Lynn MR, Knafl GJ, et al. A study of error reporting by nurses: the significant impact of nursing
team dynamics. J Res Nurs. 2023;28(5):354-364. doi:10.1177/17449871231194180.
https://psnet.ahrq.gov/is…
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www.ahrq.gov/hai/cusp/modules/implement/index.html
July 01, 2018 - Implement Teamwork and Communication
The Implement Teamwork and Communication module of the CUSP Toolkit will help you to identify barriers to communication.
The Implement Teamwork and Communication module of the CUSP Toolkit will help you to—
Understand the importance of effective communication…
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digital.ahrq.gov/ahrq-funded-projects/prism-personalized-reminders-immunizations-using-short-messaging-systems/citation/effect
January 01, 2023 - Effect of electronic health record reminders for routine immunizations and immunizations needed for chronic medical conditions.
Citation
Stephens AB, Wynn CS, Hofstetter AM, Kolff C, Pena O, Kahn E, Dasgupta B, Natarajan K, Vawdrey DK, Lane MM, Robbins-Milne L, Ramakrishnan R, Holleran S, Stockwell MS…