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psnet.ahrq.gov/issue/strategies-improving-patient-safety-culture-hospitals-systematic-review
February 14, 2017 - Review
Strategies for improving patient safety culture in hospitals: a systematic review.
Citation Text:
Morello RT, Lowthian JA, Barker AL, et al. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual Saf. 2013;22(1):11-8. doi:10.1136/bmjqs-2011-0…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/twomorees-slides/Two-More-Es-and-How-to-Spread-Dec-13-2011-508.ppt
January 01, 2011 - Project Report - Lean Sigma
Two More E’s and How to Spread
Learning Objectives
To think ahead about ways to make your investment of time and improvements in BSI rates last forever
To make sure all patients in your institution have access to the same level of safety in their care
Implementation Framework
Al…
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www.ahrq.gov/ncepcr/reports/2024-annual-report/spotlight-s1-grant.html
May 01, 2024 - Investments in Primary Care Research for 2021 and 2022
S1: Developing a Dashboard To Help Clinical Teams Prioritize and Manage Vulnerable Patients
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Table of Contents
Investments in Primary Care Research for 2021 and 2022
Acknowledgments and Authors
Message from the Acting …
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www.ahrq.gov/ncepcr/reports/2024-annual-report/appendix-d-emerging.html
May 01, 2024 - Investments in Primary Care Research for 2021 and 2022
Emerging Research Spotlights
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Table of Contents
Investments in Primary Care Research for 2021 and 2022
Acknowledgments and Authors
Message from the Acting Director of AHRQ's National Center for Excellence in Primary Ca…
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psnet.ahrq.gov/issue/exploring-health-care-professionals-perceptions-incidents-and-incident-reporting
August 28, 2013 - Study
Exploring health care professionals' perceptions of incidents and incident reporting in rehabilitation settings.
Citation Text:
Espin S, Carter C, Janes N, et al. Exploring Health Care Professionals' Perceptions of Incidents and Incident Reporting in Rehabilitation Settings. J Pati…
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www.ahrq.gov/evidencenow/projects/state/meeting-summary-cooperatives/appendix-a.html
October 01, 2024 - Building State Cooperatives for Healthcare Improvement: Meeting Summary
Appendix A: Meeting Agenda
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Table of Contents
Building State Cooperatives for Healthcare Improvement: Meeting Summary
Introduction
Meeting Sessions and Takeaways
Appendix A: Meeting Agenda
Appendix…
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psnet.ahrq.gov/issue/human-factor-cardiac-surgery-errors-and-near-misses-high-technology-medical-domain
June 09, 2010 - Review
Classic
Human factor in cardiac surgery: errors and near misses in a high technology medical domain.
Citation Text:
Carthey J, de Leval MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Tho…
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psnet.ahrq.gov/issue/effect-structured-medication-review-followed-face-face-feedback-prescribers-adverse-drug
January 18, 2013 - Study
The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study.
Citation Text:
Klopotowska JE, Kuks PFM, Wierenga PC, et al. The effect o…
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psnet.ahrq.gov/issue/improving-specificity-drug-drug-interaction-alerts-can-it-be-done
September 07, 2022 - Study
Improving the specificity of drug-drug interaction alerts: can it be done?
Citation Text:
Reese T, Wright A, Liu S, et al. Improving the specificity of drug-drug interaction alerts: Can it be done? Am J Health Syst Pharm. 2022;79(13):1086-1095. doi:10.1093/ajhp/zxac045.
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psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-chemotherapy-preparation-process
March 09, 2022 - Study
Healthcare failure mode and effect analysis in the chemotherapy preparation process.
Citation Text:
Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. Healthcare failure mode and effect analysis in the chemotherapy preparation process. J Oncol Pharm Pract. 2021;27(7):15…
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psnet.ahrq.gov/issue/how-will-we-know-patients-are-safer-organization-wide-approach-measuring-and-improving-safety
May 20, 2009 - Study
How will we know patients are safer? An organization-wide approach to measuring and improving safety.
Citation Text:
Pronovost P, Holzmueller CG, Needham DM, et al. How will we know patients are safer? An organization-wide approach to measuring and improving safety. Crit Care Med…
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psnet.ahrq.gov/issue/electronic-medication-reconciliation-tools-aimed-healthcare-professionals-support-medication
December 02, 2020 - Review
Electronic medication reconciliation tools aimed at healthcare professionals to support medication reconciliation: a systematic review.
Citation Text:
Ciudad-Gutiérrez P, del Valle-Moreno P, Lora-Escobar SJ, et al. Electronic medication reconciliation tools aimed at healthcare pro…
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digital.ahrq.gov/principal-investigator/avidan-michael
October 14, 2020 - Avidan, Michael
Exploring patient perspectives on telemedicine monitoring within the operating room.
Citation
Abraham J, Meng A, Holzer KJ, Brawer L, Casarella A, Avidan M, Politi MC. Exploring patient perspectives on telemedicine monitoring within the operating room. Int J Me…
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digital.ahrq.gov/principal-investigator/melnick-edward
January 01, 2023 - Melnick, Edward
Clinical Decision Support for Mild Traumatic Brain Injury - Final Report
Citation
Melnick, E. Clinical Decision Support for Mild Traumatic Brain Injury - Final Report. (Prepared by Yale University under Grant No. K08 HS021271). Rockville, MD: Agency for Health…
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psnet.ahrq.gov/issue/development-measure-patient-safety-event-learning-responses
June 28, 2010 - Study
Development of a measure of patient safety event learning responses.
Citation Text:
Ginsburg LR, Chuang Y-T, Norton PG, et al. Development of a measure of patient safety event learning responses. Health Serv Res. 2009;44(6):2123-47. doi:10.1111/j.1475-6773.2009.01021.x.
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psnet.ahrq.gov/issue/nurse-workarounds-electronic-health-record-integrative-review
November 18, 2020 - Review
Nurse workarounds in the electronic health record: an integrative review.
Citation Text:
Fraczkowski D, Matson J, Lopez KD. Nurse workarounds in the electronic health record: an integrative review. J Am Med Inform Assoc. 2020;27(7):1149-1165. doi:10.1093/jamia/ocaa050.
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digital.ahrq.gov/sites/default/files/docs/citation/ddi-non-interruptive-alerts-poster-2013.pdf
January 01, 2013 - 56
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Niacins + Statins (Inpatient) Niacins + Statins (Outpatient)
Alerts Overridden Alerts Generated
U.S. System
In the U.S. system, the Niacin + Statin
interaction was triggered and overridden most
often in both inpatient and outpatient systems.
U.K. …
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www.ahrq.gov/cpi/about/organization/nac/nac-amd2000.html
April 01, 2014 - Amendment to Charter
National Advisory Council for Healthcare Research and Quality (Formerly the National Advisory Council for Health Care Policy, Research, and Evaluation)
Purpose
The Council is to advise the Secretary of HHS and the Director of the Agency for Healthcare Research and Quality (AHRQ), on mat…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/clinical-case-scenarios.html
July 01, 2023 - Clinical Case Scenarios
AHRQ Safety Program for Perinatal Care, Phase 2
The two clinical case scenarios below illustrate 10 teamwork tools and strategies for improving perinatal care. One scenario focuses on obstetric hemorrhage, and the other scenario focuses on severe hypertension in pregnancy. Both scena…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/carayon-p-et
January 01, 2023 - Carayon P et al. 2009 "Implementation of an electronic health records system in a small clinic: the viewpoint of clinic staff."
Reference
Carayon P, Smith P, Hundt AS, et al. Implementation of an electronic health records system in a small clinic: the viewpoint of clinic staff. Behaviour & Information…