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psnet.ahrq.gov/issue/ethical-and-legal-issues-use-health-information-technology-improve-patient-safety
July 30, 2014 - Review
Ethical and legal issues in the use of health information technology to improve patient safety.
Citation Text:
Berner ES. Ethical and legal issues in the use of health information technology to improve patient safety. HEC Forum. 2008;20(3):243-58. doi:10.1007/s10730-008-9074-5. …
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www.ahrq.gov/news/newsroom/case-studies/201525.html
September 01, 2015 - AHRQ’s Medical Office Survey Helps Colorado Hospital Provide Better Care
Search All Impact Case Studies
September 2015
Yuma District Hospital and Clinics, a 15-bed hospital with two rural health clinics in northeast Colorado, has used results from an AHRQ-developed patient safety survey, the Medical Office…
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psnet.ahrq.gov/issue/safety-stop-valuable-addition-pediatric-universal-protocol
June 21, 2015 - Commentary
Safety stop: a valuable addition to the pediatric universal protocol.
Citation Text:
Caruso TJ, Munshey F, Aldorfer B, et al. Safety Stop: A Valuable Addition to the Pediatric Universal Protocol. Jt Comm J Qual Patient Saf. 2018;44(9):552-556. doi:10.1016/j.jcjq.2018.03.015.
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psnet.ahrq.gov/issue/heroism-safe-design-leveraging-technology
August 17, 2017 - Commentary
From heroism to safe design: leveraging technology.
Citation Text:
Pronovost P, Bo-Linn GW, Sapirstein A. From heroism to safe design: leveraging technology. Anesthesiology. 2014;120(3):526-9. doi:10.1097/ALN.0000000000000127.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/059-nursing-protocol-nasal-mupirocin.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
Nursing Decolonization Protocol:
Nasal Mupirocin
ICU & Non-ICU
Note: Mupirocin should generally be chosen over iodophor when possible. A recent study showed a mupirocin & chlorhexidine gluconate (CHG) decolonization strategy to be more effective at reducing Staphylococcus aureus …
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psnet.ahrq.gov/issue/multidisciplinary-crisis-simulations-way-forward-training-surgical-teams
July 31, 2008 - Study
Multidisciplinary crisis simulations: the way forward for training surgical teams.
Citation Text:
Undre S, Koutantji M, Sevdalis N, et al. Multidisciplinary crisis simulations: the way forward for training surgical teams. World J Surg. 2007;31(9):1843-53.
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psnet.ahrq.gov/issue/organizational-and-intraorganizational-development-disasters
May 12, 2021 - Review
Classic
The organizational and intraorganizational development of disasters.
Citation Text:
Turner BA. The Organizational and Interorganizational Development of Disasters. Adm Sci Q. 1976;21(3):378. doi:10.2307/2391850.
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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/improving-quality-discharge-communication-educational-intervention
April 24, 2018 - Study
Improving the quality of discharge communication with an educational intervention.
Citation Text:
Key-Solle M, Paulk E, Bradford K, et al. Improving the quality of discharge communication with an educational intervention. Pediatrics. 2010;126(4):734-9. doi:10.1542/peds.2010-0884.
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psnet.ahrq.gov/issue/reducing-administrative-harm-medicine-clinicians-and-administrators-together
February 23, 2022 - Commentary
Reducing administrative harm in medicine - clinicians and administrators together.
Citation Text:
O’Donnell WJ. Reducing administrative harm in medicine - clinicians and administrators together. N Engl J Med. 2022;386(25):2429-2432. doi:10.1056/nejmms2202174.
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psnet.ahrq.gov/issue/identifying-cross-contaminants-and-specimen-mix-ups-surgical-pathology
July 22, 2020 - Review
Identifying cross contaminants and specimen mix-ups in surgical pathology.
Citation Text:
Hunt JL. Identifying cross contaminants and specimen mix-ups in surgical pathology. Adv Anat Pathol. 2008;15(4):211-7. doi:10.1097/PAP.0b013e31817bf596.
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psnet.ahrq.gov/issue/2-year-study-patient-safety-competency-assessment-29-clinical-laboratories
December 14, 2016 - Study
A 2-year study of patient safety competency assessment in 29 clinical laboratories.
Citation Text:
Reed RC, Kim S, Farquharson K, et al. A 2-Year Study of Patient Safety Competency Assessment in 29 Clinical Laboratories. Am J Clin Pathol. 2008;129(6). doi:10.1309/bm8jje1auca408tq…
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psnet.ahrq.gov/issue/systems-approach-and-systems-engineering-applied-health-care-improving-patient-safety-and
August 12, 2020 - Commentary
Systems approach and systems engineering applied to health care: improving patient safety and health care delivery.
Citation Text:
Systems approach and systems engineering applied to health care: improving patient safety and health care delivery. Ravitz AD, Sapirstein A, Pha…
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psnet.ahrq.gov/issue/improving-healthcare-quality-through-organisational-peer-peer-assessment-lessons-nuclear
May 24, 2012 - Commentary
Improving healthcare quality through organisational peer-to-peer assessment: lessons from the nuclear power industry.
Citation Text:
Pronovost P, Hudson DW. Improving healthcare quality through organisational peer-to-peer assessment: lessons from the nuclear power industry. …
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psnet.ahrq.gov/issue/epidemiology-prescribing-errors-potential-impact-computerized-prescriber-order-entry
May 04, 2010 - Study
The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry.
Citation Text:
Bobb A, Gleason KM, Husch M, et al. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med. 2004;164(7…
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psnet.ahrq.gov/issue/detection-and-measurement-rotator-cuff-tears-sonography-analysis-diagnostic-errors
December 31, 2014 - Study
Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors.
Citation Text:
Teefey SA, Middleton WD, Payne WT, et al. Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors. AJR Am J Roentgenol. 2005;184(6…
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psnet.ahrq.gov/issue/management-adverse-surgical-events-structured-education-module-residents
August 26, 2011 - Study
Management of adverse surgical events: a structured education module for residents.
Citation Text:
Brewster LP, Risucci DA, Joehl RJ, et al. Management of adverse surgical events: a structured education module for residents. Am J Surg. 2005;190(5):687-90.
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psnet.ahrq.gov/issue/standardized-sign-out-reduces-intern-perception-medical-errors-general-internal-medicine-ward
August 04, 2021 - Study
Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward.
Citation Text:
Salerno SM, Arnett M, Domanski JP. Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward. Teach Learn Med. 200…
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psnet.ahrq.gov/issue/using-survey-incident-reporting-and-learning-practices-improve-organisational-learning-cancer
June 30, 2011 - Study
Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care centre.
Citation Text:
Cooke DL, Dunscombe PB, Lee R. Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care ce…
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psnet.ahrq.gov/issue/broselow-tape-effective-medication-dosing-instrument-review-literature
April 09, 2009 - Review
The Broselow tape as an effective medication dosing instrument: a review of the literature.
Citation Text:
Meguerdichian MJ, Clapper TC. The Broselow tape as an effective medication dosing instrument: a review of the literature. J Pediatr Nurs. 2012;27(4):416-420. doi:10.1016/j.…