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psnet.ahrq.gov/issue/novel-process-audit-standardized-perioperative-handoff-protocols
June 27, 2018 - Commentary
A novel process audit for standardized perioperative handoff protocols.
Citation Text:
Pallekonda V, Scholl AT, McKelvey GM, et al. A Novel Process Audit for Standardized Perioperative Handoff Protocols. Jt Comm J Qual Patient Saf. 2017;43(11):611-618. doi:10.1016/j.jcjq.2017.…
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psnet.ahrq.gov/issue/barriers-and-facilitators-injection-safety-ambulatory-care-settings
November 18, 2016 - Review
Barriers and facilitators to injection safety in ambulatory care settings.
Citation Text:
Leback C, Johnson DH, Anderson L, et al. Barriers and Facilitators to Injection Safety in Ambulatory Care Settings. Infect Control Hosp Epidemiol. 2018;39(7):841-848. doi:10.1017/ice.2018.82.…
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psnet.ahrq.gov/issue/global-oximetry-international-anaesthesia-quality-improvement-project
November 12, 2014 - Study
Global oximetry: an international anaesthesia quality improvement project.
Citation Text:
Walker IA, Merry AF, Wilson IH, et al. Global oximetry: an international anaesthesia quality improvement project. Anaesthesia. 2009;64(10):1051-60. doi:10.1111/j.1365-2044.2009.06067.x.
Co…
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psnet.ahrq.gov/issue/effect-evidence-crisis-learning-based-perspective-integration-framework
March 24, 2019 - Commentary
The effect of evidence in crisis learning: based on a perspective integration framework.
Citation Text:
Wang B, Li D, Wang Y. The effect of evidence in crisis learning: based on a perspective integration framework. J Contingencies Crisis Manag. 2024;32(1):e12506. doi:10.1111/1…
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psnet.ahrq.gov/issue/nurses-use-computerized-clinical-guidelines-improve-patient-safety-hospitals
June 06, 2018 - Review
Nurses' use of computerized clinical guidelines to improve patient safety in hospitals.
Citation Text:
Hovde B, Jensen KH, Alexander GL, et al. Nurses' Use of Computerized Clinical Guidelines to Improve Patient Safety in Hospitals. West J Nurs Res. 2015;37(7):877-98. doi:10.1177/0…
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www.ahrq.gov/news/newsroom/case-studies/ktcquips92.html
October 01, 2014 - Maryland Hospitals Revise Medication Reconciliation Process With AHRQ Toolkit
Search All Impact Case Studies
April 2012
After participating in AHRQ-sponsored learning sessions and provider support calls, Delmarva Foundation for Medical Care, the Maryland Quality Improvement Organization (QIO), worked with h…
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psnet.ahrq.gov/issue/effects-safety-checklists-medicine-systematic-review
December 07, 2011 - Review
The effects of safety checklists in medicine: a systematic review.
Citation Text:
Thomassen Ø, Storesund A, Søfteland E, et al. The effects of safety checklists in medicine: a systematic review. Acta Anaesthesiol Scand. 2014;58(1):5-18. doi:10.1111/aas.12207.
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psnet.ahrq.gov/issue/leveraging-trainees-improve-quality-and-safety-point-care-three-models-engagement
September 20, 2017 - Commentary
Leveraging trainees to improve quality and safety at the point of care: three models for engagement.
Citation Text:
Faherty LJ, Mate KS, Moses JM. Leveraging Trainees to Improve Quality and Safety at the Point of Care: Three Models for Engagement. Acad Med. 2016;91(4):503-9. d…
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psnet.ahrq.gov/issue/sources-and-magnitude-error-preparing-morphine-infusions-nurse-patient-controlled-analgesia
January 07, 2015 - Study
Sources and magnitude of error in preparing morphine infusions for nurse–patient controlled analgesia in a UK paediatric hospital.
Citation Text:
Rashed AN, Tomlin S, Aguado V, et al. Sources and magnitude of error in preparing morphine infusions for nurse-patient controlled analge…
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psnet.ahrq.gov/issue/mental-models-basic-concept-human-factors-design-infection-prevention
April 26, 2017 - Commentary
Mental models: a basic concept for human factors design in infection prevention.
Citation Text:
Sax H, Clack L. Mental models: a basic concept for human factors design in infection prevention. J Hosp Infect. 2015;89(4):335-9. doi:10.1016/j.jhin.2014.12.008.
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psnet.ahrq.gov/issue/work-overload-related-increased-risk-error-during-chemotherapy-preparation
June 30, 2011 - Study
Work overload is related to increased risk of error during chemotherapy preparation.
Citation Text:
Carrez L, Bouchoud L, Fleury S, et al. Work overload is related to increased risk of error during chemotherapy preparation. J Oncol Pharm Pract. 2019;25(6):1456-1466. doi:10.1177/107…
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psnet.ahrq.gov/issue/beliefs-ambulatory-care-physicians-about-accuracy-patient-medication-records-and-technology
December 03, 2014 - Study
Beliefs of ambulatory care physicians about accuracy of patient medication records and technology-enhanced solutions to improve accuracy.
Citation Text:
Weeks DL, Corbett CF, Stream G. Beliefs of ambulatory care physicians about accuracy of patient medication records and technolo…
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psnet.ahrq.gov/issue/human-factors-engineering-tool-medical-device-evaluation-hospital-procurement-decision-making
June 28, 2017 - Study
Human factors engineering: a tool for medical device evaluation in hospital procurement decision-making.
Citation Text:
Ginsburg G. Human factors engineering: a tool for medical device evaluation in hospital procurement decision-making. J Biomed Inform. 2005;38(3):213-9.
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psnet.ahrq.gov/issue/right-medication-right-dose-right-patient-right-time-and-right-route-how-do-we-select-right
March 02, 2016 - Commentary
Right medication, right dose, right patient, right time, and right route: how do we select the right patient-controlled analgesia (PCA) device?
Citation Text:
Ladak SSJ, Chan VWS, Easty T, et al. Right medication, right dose, right patient, right time, and right route: how d…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-gray-sops-action-planning-tool.pdf
June 02, 2025 - Action Planning for the SOPS Surveys-Introducing SOPS
10
Introducing the SOPS Action
Planning Tool
Laura Gray, MPH
Senior Study Director,
User Network for the AHRQ Surveys on Patient Safety Culture
(SOPS)
Westat
11
AHRQ Surveys on Patient Safety Culture
Surveys of clinicians and staff about the extent to
w…
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psnet.ahrq.gov/issue/safe-electronic-health-record-use-requires-comprehensive-monitoring-and-evaluation-framework
May 22, 2015 - Commentary
Safe electronic health record use requires a comprehensive monitoring and evaluation framework.
Citation Text:
Sittig DF, Classen D. Safe electronic health record use requires a comprehensive monitoring and evaluation framework. JAMA. 2010;303(5):450-451. doi:10.1001/jama.20…
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psnet.ahrq.gov/issue/read-back-improves-information-transfer-simulated-clinical-crises
March 12, 2017 - Study
Read-back improves information transfer in simulated clinical crises.
Citation Text:
Boyd M, Cumin D, Lombard B, et al. Read-back improves information transfer in simulated clinical crises. BMJ Qual Saf. 2014;23(12):989-93. doi:10.1136/bmjqs-2014-003096.
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psnet.ahrq.gov/issue/whats-your-kit-safety-checkup-may-be-order
September 24, 2010 - Commentary
What's in your kit? A safety checkup may be in order.
Citation Text:
Paparella S. What's In Your Kit? A Safety Checkup May Be In Order. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association. 2015;41(6):513-5. doi:10.1016/j.jen.…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/mowebinar_2014/funaro-0914slides.pdf
January 01, 2014 - Success Stories from the AHRQ Medical Office Survey on Patient Safety Culture
45
45
YUMA DISTRICT HOSPITAL AND
CLINICS
Bev Funaro, RN
Director of Quality and Regulatory Affairs
46
46
Yuma Clinic Background
• Participate in the Hospital and Medical Office
surveys
• Administered survey in 2011 and 2…
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psnet.ahrq.gov/issue/simulation-and-diagnostic-process-pilot-study-trauma-and-rapid-response-teams
July 16, 2015 - Study
Simulation and the diagnostic process: a pilot study of trauma and rapid response teams.
Citation Text:
Juriga LL, Murray DJ, Boulet JR, et al. Simulation and the diagnostic process: a pilot study of trauma and rapid response teams. Diagnosis (Berl). 2017;4(4):241-249. doi:10.1515/…