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9841. Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-1.pdf
      March 01, 2020 - Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room Patient Identification Errors in the Operating Room 11-1 11. Patient Identification Errors in the Operating Room Authors: Cori Sheedy, Ph.D., and Sonja Richard, M.P.H. Introduction In the first Making Health Care Safer …

9842. Final Progress Report: Creating Learning Cultures Around Mistakes for Residents (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/hoff-report.pdf
      January 01, 2024 - Final Progress Report: Creating Learning Cultures Around Mistakes for Residents 1 Project Title: Creating Learning Cultures Around Mistakes for Residents Timothy J. Hoff, PhD, Principal Investigator University at Albany, SUNY School of Public Health Henry Pohl, MD, Co-Investigator Joel Bartfield, MD, Co-Investi…

9843. Improving Workplace Safety in Hospitals: A Resource List for Users of the AHRQ Workplace Safety Supplemental Item Set (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/workplace-safety-resources.pdf
      May 01, 2023 - Improving Workplace Safety in Hospitals: A Resource List for Users of the AHRQ Workplace Safety Supplemental Item Set SOPS Workplace Safety for Hospitals Supplemental Item Set Resource List 1 Improving Workplace Safety in Hospitals: A Resource List for Users of the AHRQ Workplace Safety Supplemental Item Set I…

9844. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
      January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx Spotlight The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Source and Credits • This presentation is based on the November 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahr…

9845. Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Baker_107.pdf
      March 30, 2008 - Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Donald K. Baker, PharmD; James M. Hoffman, PharmD; Gregory A. Hal…

9846. VHA’s National Falls Collaborative and Prevention Programs (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Stalhandske2_70.pdf
      March 01, 2006 - VHA’s National Falls Collaborative and Prevention Programs VHA’s National Falls Collaborative and Prevention Programs Erik Stalhandske, MPP, MHSA; Peter Mills, PhD; Pat Quigley, PhD, ARNP, CRRN, FAAN; Julia Neily, MS, MPH; James P. Bagian, MD, PE Abstract Falls are a high-volume, high-cost problem in he…

9847. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
      July 01, 2003 - Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors 185 Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors Emily Beth Devine, Jennifer L. Wilson-Norton, Nathan M. Lawless, Thomas K. Hazlet, R…

9848. Identifying Barriers to the Success of a Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harper.pdf
      March 01, 2004 - Identifying Barriers to the Success of a Reporting System 167 Identifying Barriers to the Success of a Reporting System Michelle L. Harper, Robert L. Helmreich Abstract Spurred by a controversial report from the Institute of Medicine on the prevalence of medical error, To Err Is Human, the medical profe…

9849. Creating a Curriculum for Training Health Profession Faculty Leaders (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Mitchell.pdf
      March 31, 2004 - Creating a Curriculum for Training Health Profession Faculty Leaders 299 Creating a Curriculum for Training Health Profession Faculty Leaders Pamela H. Mitchell, Lynne S. Robins, Douglas Schaad Abstract Objectives: An interprofessional, collaborative group of educators, patient safety officers, and Federal …

9850. Proactive Postmarketing Surveillance: Overview and Lessons Learned from Medication Safety Research in the Veterans Health Administration (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell-R_106.pdf
      April 14, 2008 - Proactive Postmarketing Surveillance: Overview and Lessons Learned from Medication Safety Research in the Veterans Health Administration Proactive Postmarketing Surveillance: Overview and Lessons Learned from Medication Safety Research in the Veterans Health Administration Robert R. Campbell, JD, MPH, PhD; An…

9851. Implementing a Patient Safety Program at a Large National Health System | PSNet
      psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
      January 01, 2008 - Implementing a Patient Safety Program at a Large National Health System Loran Hauck, MD, and Jan Jacob, MBA, RN | January 1, 2008  Also Read a Conversation View more articles from the same authors. Citation Text: Hauck LD, Jacob J. Implementing a Patient Safety …

9852. Primary Care Practice Facilitation Curriculum Module 9: Using Appreciative Inquiry with Practices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-9-appreciative-inquiry.pdf
      September 01, 2015 - Primary Care Practice Facilitation Curriculum Module 9: Using Appreciative Inquiry with Practices Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Primary Care Practice Facilitation Curriculum Module 9: Using Appreciative Inquiry with Practices …

9853. Final Progress Report: The Effect of EMR on Medication Safety: A SPUR-Net Study (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/kuo-report.pdf
      January 01, 2024 - Final Progress Report: The Effect of EMR on Medication Safety: A SPUR-Net Study AHRQ grant final progress report TITLE The Effect of EMR on Medication Safety: A SPUR-Net Study PRINCIPAL INVESTIGATORS AND TEAM MEMBERS Principal Investigator: Grace M. Kuo, PharmD, MPH Study Co-Investigators: Jeffrey R. Steinbauer,…

9854. Final Progress Report: Are Volume Standards Accurate Measures? (pdf file)
      www.ahrq.gov/sites/default/files/2024-10/glance-report.pdf
      January 01, 2024 - Final Progress Report: Are Volume Standards Accurate Measures? FINAL PROGRESS REPORT: ARE VOLUME STANDARDS ACCURATE MEASURES? Principal Investigator: Laurent G. Glance, M.D. Co-Investigators: Andrew W. Dick, Ph.D. Turner M. Osler, M.D. Dana B. Mukamel, Ph.D. Organization: University of Rochester School of Medic…

9855. Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/czeisler-report.pdf
      January 01, 2024 - Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety Final Progress Report Title: Effects of Extended Work Hours on ICU Patient Safety Principal Investigator: Charles A. Czeisler, Ph.D., M.D. Organization: Brigham and Women's Hospital Co-Investigators: Christopher P. Landrigan, M.D., M.P.H.…

9856. Final Progress Report: Improving Safety and Quality with Outpatient Order Entry (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/gandhi-report.pdf
      January 01, 2024 - Final Progress Report: Improving Safety and Quality with Outpatient Order Entry Grant Final Report Grant ID: 5R01HS015226-03 Improving Safety and Quality with Outpatient Order Entry Inclusive dates: 09/03/04 - 08/31/08 Principal Investigator: Tejal K. Gandhi, MD, MPH Team members: Eric G. Poon, MD, MPH Thomas D.…

9857. Final Report: Improving Drug Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/magid-report.pdf
      January 01, 2024 - Final Report: Improving Drug Safety Final Report: Improving Drug Safety PI: David Magid, MD, MPH Co-PI: Marsha Raebel, PharmD Project Manager: David Brand, MSPH Project Staff: Bates, David, MD Chester, Elizabeth, PharmD Glasgow, Russell, PhD Nelson, Kent, PharmD Palen, Ted, MD, PhD Platt, Richard, MD, MSc…

9858. In Conversation With… Matthew Weinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
      August 01, 2018 - In Conversation With… Matthew Weinger, MD August 1, 2018  Also Read an Essay Citation Text: In Conversation With… Matthew Weinger, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …

9859. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
      January 01, 2004 - Quantitative and Qualitative Analysis of Medication Errors: The New York Experience 131 Quantitative and Qualitative Analysis of Medication Errors: The New York Experience Elizabeth Duthie, Barbara Favreau, Angelo Ruperto, Janet Mannion, Ellen Flink, Ruth Leslie Abstract Objectives: In June 2000, the New Yo…

9860. Final Progress Report: EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/vaughan-report.pdf
      January 01, 2024 - Final Progress Report: EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) Title: EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) PI: E. Camille Vaughan, MD, MS Team Members Emory/Grady: Ann…