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psnet.ahrq.gov/issue/using-delphi-method-identify-human-factors-contributing-nursing-errors
June 10, 2015 - Study
Using a Delphi method to identify human factors contributing to nursing errors.
Citation Text:
Roth C, Brewer M, Wieck L. Using a Delphi Method to Identify Human Factors Contributing to Nursing Errors. Nurs Forum. 2017;52(3):173-179. doi:10.1111/nuf.12178.
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psnet.ahrq.gov/issue/three-perspectives-changes-resident-work-environment-and-duty-hours
September 02, 2020 - Commentary
Three perspectives on changes in resident work environment and duty hours.
Citation Text:
Three perspectives on changes in resident work environment and duty hours. Bilimoria KY, Meyers MO, Mouawad NJ, et al. JAMA Surg. 2017;152(10):903-908.
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psnet.ahrq.gov/issue/hipaa-and-patient-care-role-professional-judgment
June 22, 2022 - Commentary
HIPAA and patient care: the role for professional judgment.
Citation Text:
Lo B, Dornbrand L, Dubler NN. HIPAA and patient care: the role for professional judgment. JAMA. 2005;293(14):1766-71.
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psnet.ahrq.gov/issue/utility-and-assessment-non-technical-skills-rapid-response-systems-and-medical-emergency
June 22, 2009 - Review
Utility and assessment of non-technical skills for rapid response systems and medical emergency teams.
Citation Text:
Chalwin RP, Flabouris A. Utility and assessment of non-technical skills for rapid response systems and medical emergency teams. Intern Med J. 2013;43(9):962-9. d…
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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/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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psnet.ahrq.gov/issue/duration-anesthesia-indicator-morbidity-and-mortality-office-based-facial-plastic-surgery
March 19, 2018 - Study
Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery: a review of 1200 consecutive cases.
Citation Text:
Gordon NA, Koch ME. Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surger…
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www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/rule.html
May 01, 2023 - Tool: Two-Challenge Rule
The Two-Challenge Rule is another tool used to facilitate team members' speaking up. It was developed to manage conflict when team members’ perception of a situation differs. Human factor experts developed the rule to help airline captains prevent disasters when otherwise excellent deci…
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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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www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/advocacy.html
June 01, 2023 - Tool: Advocacy and Assertion
Providing mutual support also sometimes requires the use of advocacy and assertion. Advocacy and assertion interventions are invoked when a team member's viewpoint does not coincide with that of a decision maker. In advocating by or for the patient and asserting the need for correct…
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psnet.ahrq.gov/issue/essay-political-logic-regulatory-error
July 10, 2017 - Commentary
Essay: the political logic of regulatory error.
Citation Text:
Carpenter D, Ting MM. Essay: the political logic of regulatory error. Nat Rev Drug Discov. 2005;4(10):819-23.
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psnet.ahrq.gov/issue/learning-safe-prescribing-during-post-take-ward-rounds
August 14, 2013 - Newspaper/Magazine Article
Learning safe prescribing during post-take ward rounds.
Citation Text:
Conroy-Smith E, Herring R, Caldwell G. Learning safe prescribing during post-take ward rounds. The clinical teacher. 2011;8(2):75-8. doi:10.1111/j.1743-498X.2011.00432.x.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/training-tools-material-guide.docx
May 01, 2017 - Overview
Definition of Sustainability and its Importance in Quality Improvement
· Slides 4-8
Linking Sustainability and Spread
· Slides 9-10
Planning Early for Sustainability
· Slides 11-12
Barriers and Solutions to Sustaining Improvements
· Slides 13-17
Steps to Creating and Implementing a Sustainability Plan
· Slides…
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psnet.ahrq.gov/issue/implementing-aorn-recommended-practices-transfer-patient-care-information
October 07, 2013 - Commentary
Implementing AORN recommended practices for transfer of patient care information.
Citation Text:
Seifert PC. Implementing AORN recommended practices for transfer of patient care information. AORN J. 2012;96(5):475-93. doi:10.1016/j.aorn.2012.08.011.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/sustainability-tool.docx
May 01, 2017 - AHRQ Safety Program for Ambulatory Surgery
Module 4: Sustainability
Sustainability Tool
Background: This tool can be used to identify sustainability issues in planning and implementing your improvement efforts.
How to use this tool: The Implementation Team leader (or individual designated by the leader) should comple…
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psnet.ahrq.gov/issue/patient-safety-what-really-issue
October 18, 2017 - Commentary
Patient safety: what is really at issue?
Citation Text:
Bagian JP. Patient safety: what is really at issue? Front Health Serv Manage. 2005;22(1):3-16.
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psnet.ahrq.gov/issue/radiation-protection-and-dose-monitoring-medical-imaging-journey-awareness-through
May 18, 2022 - Review
Radiation protection and dose monitoring in medical imaging: a journey from awareness, through accountability, ability and action … but where will we arrive?
Citation Text:
Frush DP, Denham CR, Goske MJ, et al. Radiation Protection and Dose Monitoring in Medical Imaging. J Patien…
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www.ahrq.gov/talkingquality/plan/pay.html
November 01, 2018 - How Will You Pay for a Health Care Quality Report?
A consumer reporting project is not cheap, although there are ways to reduce costs and spread them across multiple parties (including other sponsors and participating health plans or providers). Data collection costs can range from as little as a few thousand…
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psnet.ahrq.gov/issue/mentoring-staff-members-patient-safety-leaders-clarian-safe-passage-program
January 10, 2011 - Commentary
Mentoring staff members as patient safety leaders: the Clarian Safe Passage Program.
Citation Text:
Rapala K. Mentoring staff members as patient safety leaders: the Clarian Safe Passage Program. Crit Care Nurs Clin North Am. 2005;17(2):121-126, ix.
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psnet.ahrq.gov/issue/electronic-prescribing-pediatrics-toward-safer-and-more-effective-medication-management
October 04, 2011 - Organizational Policy/Guidelines
Electronic prescribing in pediatrics: toward safer and more effective medication management.
Citation Text:
Committee 2011–2012 AA of PC on CITE. Electronic prescribing in pediatrics: toward safer and more effective medication management. Pediatrics. 2…