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psnet.ahrq.gov/issue/implementing-bar-code-medication-administration-system
May 11, 2014 - Commentary
Implementing a bar-code medication administration system.
Citation Text:
Weber RJ. Implementing a Bar-Code Medication Administration System. Hosp Pharm. 2010;43(12):1016-1022. doi:10.1310/hpj4312-1016.
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psnet.ahrq.gov/issue/human-factors-and-technology-icu
June 30, 2010 - Special or Theme Issue
Human Factors and Technology in the ICU.
Citation Text:
Human Factors and Technology in the ICU. Wung SF, ed. Crit Care Nurs Clin North Am. 2018;30:179-310.
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psnet.ahrq.gov/issue/report-faults-childrens-hospital-medication-errors
August 24, 2016 - Newspaper/Magazine Article
Report faults Children's Hospital for medication errors.
Citation Text:
Report faults Children's Hospital for medication errors. Kowalczyk L. Boston Globe. May 27, 2018.
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psnet.ahrq.gov/issue/clash-name-care
April 27, 2016 - Newspaper/Magazine Article
Clash in the name of care.
Citation Text:
Clash in the name of care. Abelson J, Saltzman J, Kowalcyzk L, Allen S. Boston Globe. October 26, 2015.
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/event-tree-analysis
January 01, 2023 - Event Tree Analysis
Acronym
ETA
Description
An event tree analysis (ETA) examines the different paths that can be taken in a given scenario. Each step consists of a node and corresponding exit lines for each possible outcome at that step. The tool was originally developed for use in system rel…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/kepner-tregoe-matrix
January 01, 2023 - Kepner-Tregoe Matrix
Also Known As
Is-Is Not Matrix
Kepner and Tregoe Method
Description
A Kepner-Tregoe matrix is used to find causes of a problem. It isolates the who, what, when, where, and how aspects of an event, keeping the focus on the elements that have an impact on the event and…
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psnet.ahrq.gov/issue/engaging-patients-improving-ambulatory-care
January 17, 2024 - Book/Report
Engaging Patients in Improving Ambulatory Care.
Citation Text:
Engaging Patients in Improving Ambulatory Care. Aligning Forces for Quality. Princeton, NJ: Robert Wood Johnson Foundation; 2013.
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psnet.ahrq.gov/issue/preventing-infections-how-portland-hospitals-compare
June 08, 2011 - Newspaper/Magazine Article
Preventing infections: how Portland hospitals compare.
Citation Text:
Preventing infections: how Portland hospitals compare. Rojas-Burke J. The Oregonian. May 8, 2010.
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psnet.ahrq.gov/issue/removing-insult-injury-disclosing-adverse-events
November 07, 2012 - Audiovisual
Removing Insult from Injury: Disclosing Adverse Events.
Citation Text:
Removing Insult from Injury: Disclosing Adverse Events. Johns Hopkins Bloomberg School of Public Health
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psnet.ahrq.gov/issue/pearls-pitfalls-and-errors-musculoskeletal-diagnosis
February 26, 2025 - Special or Theme Issue
Pearls, Pitfalls, and Errors in Musculoskeletal Diagnosis.
Citation Text:
Pearls, Pitfalls, and Errors in Musculoskeletal Diagnosis. Blankenbaker DG, ed. AJR Am J Roentgenol. 2014;203(3):476-593.
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psnet.ahrq.gov/issue/how-guides-improving-transitions-hospital-reduce-avoidable-rehospitalizations
November 18, 2011 - Special or Theme Issue
How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations.
Citation Text:
How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; Jun…
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psnet.ahrq.gov/issue/innovation-perioperative-patient-safety
January 02, 2011 - Special or Theme Issue
Innovation in Perioperative Patient Safety.
Citation Text:
Innovation in Perioperative Patient Safety. Miller DR, Merry AF, eds. Can J Anesth. 2013;60(2):7-220.
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psnet.ahrq.gov/issue/debriefing-patient-safety
December 10, 2014 - Newspaper/Magazine Article
Debriefing for patient safety.
Citation Text:
Debriefing for patient safety. Turner SH, Kurtz WD. Patient Saf Qual Healthc. November/December 2008:5:42-44,46.
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psnet.ahrq.gov/issue/defusing-disruptive-behavior-workbook-health-care-leaders
April 24, 2007 - Book/Report
Defusing Disruptive Behavior. A Workbook for Health Care Leaders.
Citation Text:
Defusing Disruptive Behavior. A Workbook for Health Care Leaders. Oakbrook, IL: Joint Commission Resources; 2007. ISBN: 9781599400846.
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psnet.ahrq.gov/issue/listening-what-matters-avoiding-contextual-errors-health-care
February 03, 2016 - Book/Report
Listening for What Matters: Avoiding Contextual Errors in Health Care.
Citation Text:
Listening for What Matters: Avoiding Contextual Errors in Health Care. Weiner SJ, Schwartz A. New York, NY: Oxford University Press; 2016. ISBN: 9780190228996.
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psnet.ahrq.gov/issue/are-workarounds-ethical-managing-moral-problems-health-care-systems
March 09, 2016 - Book/Report
Are Workarounds Ethical? Managing Moral Problems in Health Care Systems.
Citation Text:
Are Workarounds Ethical? Managing Moral Problems in Health Care Systems. Berlinger N. New York, NY: Oxford University Press; 2016. ISBN: 9780190269296.
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psnet.ahrq.gov/issue/patient-stories-2013-time-change
November 14, 2011 - Book/Report
Patient Stories 2013: Time for Change.
Citation Text:
Patient Stories 2013: Time for Change. Harrow, Middlesex, UK: The Patients Association; 2013.
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psnet.ahrq.gov/issue/zero-eliminating-unnecessary-deaths-post-pandemic-nhs
August 06, 2016 - Book/Report
Zero: Eliminating Unnecessary Deaths in a Post-pandemic NHS.
Citation Text:
Zero: Eliminating Unnecessary Deaths in a Post-pandemic NHS. Hunt J. London, UK: Swift Press; 2022. ISBN: 9781800751224.
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psnet.ahrq.gov/issue/communicating-critical-test-results
May 24, 2006 - Special or Theme Issue
Communicating Critical Test Results.
Citation Text:
Communicating Critical Test Results. Schiff GD, Bates DW, Leape LL, eds. Jt Comm J Qual Patient Saf. 2005;31(2):62-119.
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psnet.ahrq.gov/issue/patient-safety-intensive-care-unit
February 28, 2018 - Book/Report
Patient Safety in the Intensive Care Unit.
Citation Text:
Patient Safety in the Intensive Care Unit. Oak Brook, IL: Joint Commission Resources; 2010. ISBN: 9781599403144.
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