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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool10_dc_checklist.docx
November 01, 2015 - Tool 10: Discharge Process Checklist
Tool 10: Discharge PROCESS Checklist
Purpose
Provide updated guidance to readmission reduction teams for updating discharge processes, based on Centers for Medicare & Medicaid Services (CMS) documents.
Description
This tool, adapted from the CMS Conditions of Participation (CO…
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psnet.ahrq.gov/issue/care-and-outcomes-patients-hospital-stroke
September 18, 2024 - Study
Care and outcomes of patients with in-hospital stroke.
Citation Text:
Saltman AP, Silver FL, Fang J, et al. Care and Outcomes of Patients With In-Hospital Stroke. JAMA Neurol. 2015;72(7):749-55. doi:10.1001/jamaneurol.2015.0284.
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psnet.ahrq.gov/issue/evaluating-safety-and-competency-bedside
November 16, 2022 - Commentary
Evaluating safety and competency at the bedside.
Citation Text:
Kaplan T, Pilcher J. Evaluating safety and competency at the bedside. J Nurses Staff Dev. 2011;27(4):187-90. doi:10.1097/NND.0b013e3182236634.
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psnet.ahrq.gov/issue/maturity-hospitals-quality-improvement-systems-associated-measures-quality-and-patient-safety
May 26, 2014 - Study
Is the maturity of hospitals' quality improvement systems associated with measures of quality and patient safety?
Citation Text:
Groene O, Mora N, Thompson A, et al. Is the maturity of hospitals' quality improvement systems associated with measures of quality and patient safety? B…
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psnet.ahrq.gov/issue/evaluation-parenteral-nutrition-errors-era-drug-shortages
October 02, 2013 - Study
Evaluation of parenteral nutrition errors in an era of drug shortages.
Citation Text:
Storey MA, Weber RJ, Besco K, et al. Evaluation of Parenteral Nutrition Errors in an Era of Drug Shortages. Nutr Clin Pract. 2016;31(2):211-7. doi:10.1177/0884533615608820.
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psnet.ahrq.gov/issue/not-thinking-clearly-play-game-seriously
January 17, 2018 - Commentary
Not thinking clearly? Play a game, seriously!
Citation Text:
Mohan D, Schell J, Angus DC. Not Thinking Clearly? Play a Game, Seriously!. JAMA. 2016;316(18):1867-1868. doi:10.1001/jama.2016.14174.
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psnet.ahrq.gov/issue/adverse-drug-events-elderly
April 21, 2011 - Review
Adverse drug events in the elderly.
Citation Text:
Cresswell KM, Fernando B, McKinstry B, et al. Adverse drug events in the elderly. Br Med Bull. 2007;83(1). doi:10.1093/bmb/ldm016.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
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psnet.ahrq.gov/issue/patient-safety-public-health
July 19, 2023 - Commentary
Patient safety: this is public health.
Citation Text:
Card AJ. Patient safety: this is public health. J Healthc Risk Manag. 2014;34(1):6-12. doi:10.1002/jhrm.21145.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
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psnet.ahrq.gov/issue/development-standardized-citywide-process-managing-smart-pump-drug-libraries
June 07, 2017 - Commentary
Development of a standardized, citywide process for managing smart-pump drug libraries.
Citation Text:
Walroth TA, Smallwood S, Arthur KJ, et al. Development of a standardized, citywide process for managing smart-pump drug libraries. Am J Health Syst Pharm. 2018;75(12):893-900…
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psnet.ahrq.gov/issue/whats-sound-managing-alarm-fatigue
April 26, 2023 - Newspaper/Magazine Article
What's that sound? Managing alarm fatigue.
Citation Text:
George TP, Martin V. Whatʼs that sound? Managing alarm fatigue. Nursing Made Incredibly Easy!. 2014;12(5). doi:10.1097/01.nme.0000452689.19763.3f.
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psnet.ahrq.gov/issue/close-calls-patient-safety-should-we-be-paying-closer-attention
November 08, 2013 - Commentary
Close calls in patient safety: should we be paying closer attention?
Citation Text:
Wu AW, Marks CM. Close calls in patient safety: should we be paying closer attention? CMAJ. 2013;185(13):1119-20. doi:10.1503/cmaj.130014.
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psnet.ahrq.gov/issue/supporting-patient-safety-and-clinical-pharmacy-services-collaborative
February 08, 2023 - Commentary
Supporting the Patient Safety and Clinical Pharmacy Services Collaborative.
Citation Text:
Mitchell JR. Supporting the patient safety and clinical pharmacy services collaborative. Am J Health Syst Pharm. 2012;69(14):1246-50. doi:10.2146/ajhp110558.
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psnet.ahrq.gov/issue/medication-safety-initiative-reducing-medication-errors
June 09, 2015 - Study
Medication safety initiative in reducing medication errors.
Citation Text:
Nguyen EE, Connolly PM, Wong V. Medication safety initiative in reducing medication errors. J Nurs Care Qual. 2010;25(3):224-230.
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psnet.ahrq.gov/issue/partnering-pediatric-patients-and-families-high-reliability-identify-and-reduce-preventable
December 02, 2020 - Commentary
Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events.
Citation Text:
Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events. Kirby J, Cannon C, Darrah …
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psnet.ahrq.gov/issue/how-communication-failed-or-saved-day-counterfactual-accounts-medical-errors
September 21, 2022 - Study
How communication "failed" or "saved the day": counterfactual accounts of medical errors.
Citation Text:
Street RL, Petrocelli JV, Amroze A, et al. How Communication “Failed” or “Saved the Day”: Counterfactual Accounts of Medical Errors. J Patient Exp. 2020;7(6):1247-1254. doi:10.1…
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psnet.ahrq.gov/issue/problem-never-events
July 12, 2023 - Commentary
The problem with 'never events'.
Citation Text:
Zaslow J, Fortier J, Garber G. The problem with ‘never events’. BMJ Qual Saf. 2024;33(9):613-616. doi:10.1136/bmjqs-2023-016981.
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psnet.ahrq.gov/issue/network-patient-safety-databases-chartbook-2019
October 23, 2019 - Book/Report
Network of Patient Safety Databases Chartbook, 2019
Citation Text:
Network of Patient Safety Databases Chartbook, 2019 Rockville, MD: Agency for Healthcare Research and Quality; December 2019. AHRQ Pub No 20-0023.
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psnet.ahrq.gov/issue/adverse-events-hospitals-quarter-medicare-patients-experienced-harm-october-2018
February 01, 2023 - Book/Report
Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018.
Citation Text:
Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018. Grimm CA. Washington DC: Office of the Inspector General; May 2022. Repor…
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psnet.ahrq.gov/issue/effects-work-hour-reduction-residents-lives-systematic-review
March 02, 2011 - Review
Effects of work hour reduction on residents' lives: a systematic review.
Citation Text:
Fletcher KE, Underwood W, Davis SQ, et al. Effects of Work Hour Reduction on Residents’ Lives. JAMA. 2005;294(9):1088. doi:10.1001/jama.294.9.1088.
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psnet.ahrq.gov/issue/dual-process-cognitive-interventions-enhance-diagnostic-reasoning-systematic-review
March 20, 2019 - Review
Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review.
Citation Text:
Lambe KA, O'Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Qual Saf. 2016;25(10):808-820. doi:10.113…