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psnet.ahrq.gov/node/37370/psn-pdf
March 28, 2012 - Communication skills and error in the intensive care unit.
March 28, 2012
Reader TW, Flin R, Cuthbertson BH. Communication skills and error in the intensive care unit. Curr Opin
Crit Care. 2007;13(6):732-6.
https://psnet.ahrq.gov/issue/communication-skills-and-error-intensive-care-unit
This article examines how ef…
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psnet.ahrq.gov/node/37494/psn-pdf
January 23, 2008 - Physician-Owned Specialty Hospital's Ability to Manage
Medical Emergencies.
January 23, 2008
Levinson DR. Washington DC: US Department of Health and Human Services, Office of Inspector
General. January 2008, OEI-02-06-00310.
https://psnet.ahrq.gov/issue/physician-owned-specialty-hospitals-ability-manage-medic…
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psnet.ahrq.gov/node/42798/psn-pdf
June 17, 2014 - The concept of shared mental models in healthcare
collaboration.
June 17, 2014
McComb SA, Simpson V. The concept of shared mental models in healthcare collaboration. J Adv Nurs.
2014;70(7):1479-88. doi:10.1111/jan.12307.
https://psnet.ahrq.gov/issue/concept-shared-mental-models-healthcare-collaboration
This conce…
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psnet.ahrq.gov/node/37967/psn-pdf
August 27, 2009 - Life after death: the aftermath of perioperative
catastrophes.
August 27, 2009
Gazoni FM, Durieux ME, Wells L. Life after death: the aftermath of perioperative catastrophes. Anesth
Analg. 2008;107(2):591-600. doi:10.1213/ane.0b013e31817a9c77.
https://psnet.ahrq.gov/issue/life-after-death-aftermath-perioperative-ca…
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psnet.ahrq.gov/node/36930/psn-pdf
September 09, 2011 - Team structure and adverse events in home health care.
September 9, 2011
Feldman PH, Bridges J, Peng T. Team structure and adverse events in home health care. Med Care.
2007;45(6):553-61.
https://psnet.ahrq.gov/issue/team-structure-and-adverse-events-home-health-care
The investigators examined the role of team var…
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psnet.ahrq.gov/node/36396/psn-pdf
December 22, 2010 - Interdisciplinary communication: an uncharted source of
medical error?
December 22, 2010
Alvarez G, Coiera E. Interdisciplinary communication: an uncharted source of medical error? J Crit Care.
2006;21(3):236-42; discussion 242.
https://psnet.ahrq.gov/issue/interdisciplinary-communication-uncharted-source-medical-…
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hcup-us.ahrq.gov/datainnovations/CaseStudy_QDRanalysis04072017.pdf
April 07, 2017 - Because the QDR focuses on examining trends in health care in the United States, it is
essential to … Ability to Test for Significant Differences in QI Trends
Because the QDR focuses on examining trends
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/measuring-blood-pressure-surveillance-160412.pdf
May 29, 2025 - either$SBP,$DBP,$BP$control,$or$
The$conclusions$are$still$valid.$ One$cluster$RCT$(Margolis$2013)$
examining … Hg,$p<.001),$and$at$18$months$("
3.0$mm$Hg,$p$=$.07).$
$
One$multi"center$RCT$(McKinstry$
2013)$examining … $Both$experts$
recommended$
examining$evidence$
from$a$new$IPD$meta"
analysis
1
$currently$being … In$
addition,$no$form$of$additional$
support$was$examined$by$
subgroup.$
One$cluster$RCT
6
$
examining … months$("
5.1$mm$Hg,$p<.001),$and$
at$18$months$("3.0$mm$
Hg,$p$=$.07).$
One$multi"center$RCT
7
$
examining
-
psnet.ahrq.gov/node/34906/psn-pdf
June 27, 2011 - System weaknesses as contributing causes of accidents
in health care.
June 27, 2011
Ternov S, Akselsson R. System weaknesses as contributing causes of accidents in health care. Int J Qual
Health Care. 2005;17(1):5-13.
https://psnet.ahrq.gov/issue/system-weaknesses-contributing-causes-accidents-health-care
The aut…
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psnet.ahrq.gov/node/38383/psn-pdf
June 30, 2011 - A system analysis of a suboptimal surgical experience.
June 30, 2011
Lee R, Cooke DL, Richards MR. A system analysis of a suboptimal surgical experience. Patient Saf Surg.
2009;3(1):1. doi:10.1186/1754-9493-3-1.
https://psnet.ahrq.gov/issue/system-analysis-suboptimal-surgical-experience
A post-surgical complicatio…
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psnet.ahrq.gov/node/42239/psn-pdf
May 01, 2013 - The impossible workload for doctors in training.
May 1, 2013
Chen PW.
https://psnet.ahrq.gov/issue/impossible-workload-doctors-training
This newspaper article examines how duty hour restrictions have not necessarily led to trainees getting
more sleep but have resulted in trainees needing to do more work in less ti…
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psnet.ahrq.gov/node/41233/psn-pdf
March 21, 2012 - ASPEN Parenteral Nutrition Safety Summit.
March 21, 2012
Andris DA, Mirtallo JM, Guenter P, eds. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):1S-62S.
https://psnet.ahrq.gov/issue/aspen-parenteral-nutrition-safety-summit
Articles in this special issue examine parenteral nutrition administration and provide …
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psnet.ahrq.gov/node/39953/psn-pdf
October 27, 2010 - Implementing bedside handover: strategies for change
management.
October 27, 2010
McMurray A, Chaboyer W, Wallis M, et al. Implementing bedside handover: strategies for change
management. J Clin Nurs. 2010;19(17-18):2580-9. doi:10.1111/j.1365-2702.2009.03033.x.
https://psnet.ahrq.gov/issue/implementing-bedside-han…
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psnet.ahrq.gov/node/37600/psn-pdf
March 19, 2008 - Medical emergency team: a review of the literature.
March 19, 2008
Barbetti J, Lee G. Medical emergency team: a review of the literature. Nurs Crit Care. 2008;13(2):80-85.
doi:10.1111/j.1478-5153.2007.00258.x.
https://psnet.ahrq.gov/issue/medical-emergency-team-review-literature
This review examines the literature…
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psnet.ahrq.gov/node/38520/psn-pdf
September 19, 2016 - Inpatient suicide in a general hospital.
September 19, 2016
Cheng I-C, Hu F-C, Tseng M-CM. Inpatient suicide in a general hospital. Gen Hosp Psychiatry.
2009;31(2):110-5. doi:10.1016/j.genhosppsych.2008.12.008.
https://psnet.ahrq.gov/issue/inpatient-suicide-general-hospital
Suicide attempts by hospitalized patient…
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psnet.ahrq.gov/node/38974/psn-pdf
February 18, 2019 - Patient Safety and Adverse Events.
February 18, 2019
Adlassnig KP, Blobel B, Mantas J, Masic I, eds. Stud Health Technol Inform. 2009;150:497-566. In:
Medical Informatics in a United and Healthy Europe. Washington, DC: IOS Press. ISBN: 9781607500445.
https://psnet.ahrq.gov/issue/patient-safety-and-adverse-events
P…
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psnet.ahrq.gov/node/38262/psn-pdf
September 29, 2017 - Roadmap for patient safety research: approaches and
roadforks.
September 29, 2017
Hofoss D, Deilkås E. Roadmap for patient safety research: approaches and roadforks. Scand J Public
Health. 2008;36(8):812-7. doi:10.1177/1403494808096168.
https://psnet.ahrq.gov/issue/roadmap-patient-safety-research-approaches-and-ro…
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psnet.ahrq.gov/node/42443/psn-pdf
January 07, 2015 - Medical audible alarms: a review.
January 7, 2015
Edworthy J. Medical audible alarms: a review. J Am Med Inform Assoc. 2013;20(3):584-9.
doi:10.1136/amiajnl-2012-001061.
https://psnet.ahrq.gov/issue/medical-audible-alarms-review
This review examines design, implementation, and standardization concerns related to a…
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www.ahrq.gov/research/shuttered/toolkitchecklist/medcare.html
July 01, 2018 - Medical/Patient Care
Availability of other space for ancillary services. Examine general condition of facilities. Other experts will look at these areas from a different perspective.
Date: ____________ Location: _______________________ Team member: __________________________
General
Observations:
…
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www.ahrq.gov/nursing-home/resources/frontline-workers-survey.html
September 01, 2021 - Frontline Health Care Workers Survey
Resource: Frontline Health Care Workers Survey (PDF, 3.3 MB)
The partnership survey from the Kaiser Family Foundation and The Washington Post examines the experiences and attitudes of frontline healthcare workers during the coronavirus pandemic. This report highlights f…