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psnet.ahrq.gov/node/47486/psn-pdf
January 27, 2019 - Direct oral anticoagulants: a review of common
medication errors.
January 27, 2019
Barr D, Epps QJ. Direct oral anticoagulants: a review of common medication errors. J Thromb
Thrombolysis. 2019;47(1):146-154. doi:10.1007/s11239-018-1752-9.
https://psnet.ahrq.gov/issue/direct-oral-anticoagulants-review-common-medic…
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psnet.ahrq.gov/node/73424/psn-pdf
June 23, 2021 - The psychological experiences of nurses after inpatient
suicide: a meta-synthesis of qualitative research studies.
June 23, 2021
Shao Q, Wang Y, Hou K, et al. The psychological experiences of nurses after inpatient suicide: a meta?
synthesis of qualitative research studies. J Adv Nurs. 2021;77(10):4005-4016. doi:10…
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psnet.ahrq.gov/node/34888/psn-pdf
March 11, 2019 - "I wish I had seen this test result earlier!": dissatisfaction
with test result management systems in primary care.
March 11, 2019
Poon EG, Gandhi TK, Sequist TD, et al. "I wish I had seen this test result earlier!": Dissatisfaction with test
result management systems in primary care. Arch Intern Med. 2004;164(20):…
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psnet.ahrq.gov/node/46886/psn-pdf
August 01, 2018 - Support strategies for health care professionals who are
second victims.
August 1, 2018
Hauk L. Support strategies for health care professionals who are second victims. AORN J. 2018;107(6):P7-
P9. doi:10.1002/aorn.12291.
https://psnet.ahrq.gov/issue/support-strategies-health-care-professionals-who-are-second-victi…
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psnet.ahrq.gov/issue/hospitals-bid-heal-selves-saves-thousands
February 26, 2025 - Newspaper/Magazine Article
Hospitals' bid to heal selves saves thousands.
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June 28, 2006
This article article reports on the resul…
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psnet.ahrq.gov/node/43496/psn-pdf
November 01, 2016 - Designing and Delivering Whole-Person Transitional
Care: Hospital Guide to Reducing Medicaid
Readmissions.
November 1, 2016
Boutwell A, Bourgoin A , Maxwell J, et al. Rockville, MD: Agency for Healthcare Research and Quality;
September 2016. AHRQ Publication No. 16-0047-EF.
https://psnet.ahrq.gov/issue/designing-…
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psnet.ahrq.gov/node/73376/psn-pdf
June 09, 2021 - Peer support by interprofessional health care providers in
aftermath of patient safety incidents: a cross-sectional
study.
June 9, 2021
Vanhaecht K, Zeeman G, Schouten L, et al. Peer support by interprofessional health care providers in
aftermath of patient safety incidents: a cross?sectional study. J Nurs Manag. …
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psnet.ahrq.gov/node/866684/psn-pdf
September 11, 2024 - Components of pharmacist-led medication reviews and
their relationship to outcomes: a systematic review and
narrative synthesis.
September 11, 2024
Craske ME, Hardeman W, Steel N, et al. Components of pharmacist-led medication reviews and their
relationship to outcomes: a systematic review and narrative synthesis.…
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psnet.ahrq.gov/node/60614/psn-pdf
June 24, 2020 - A systems approach to analyzing and preventing hospital
adverse events.
June 24, 2020
Leveson N, Samost A, Dekker SWA, et al. A systems approach to analyzing and preventing hospital
adverse events. J Patient Saf. 2020;16(2):162-167. doi:10.1097/pts.0000000000000263.
https://psnet.ahrq.gov/issue/systems-approach-an…
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psnet.ahrq.gov/node/866272/psn-pdf
July 10, 2024 - Infection control measure performance in long-term care
hospitals and their relationship to Joint Commission
accreditation.
July 10, 2024
Schmaltz SP, Longo BA, Williams SC. Infection control measure performance in long-term care hospitals
and their relationship to Joint Commission accreditation. Jt Comm J Qual Pa…
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psnet.ahrq.gov/node/45335/psn-pdf
August 10, 2016 - The Feasibility of Determining the Effectiveness and Cost-
effectiveness of Medication Organisation Devices
Compared with Usual Care for Older People in a
Community Setting: Systematic Review, Stakeholder
Focus Groups and Feasibility RCT.
August 10, 2016
Bhattacharya D, Aldus CF, Barton G, et al. Health Tech…
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psnet.ahrq.gov/node/851353/psn-pdf
July 12, 2023 - Caregiver and clinician perspectives on discharge
medication counseling: a qualitative study.
July 12, 2023
Carroll AR, Schlundt D, Bonnet K, et al. Caregiver and clinician perspectives on discharge medication
counseling: a qualitative study. Hosp Pediatr. 2023;13(4):325-342. doi:10.1542/hpeds.2022-006937.
https:/…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/action-plan-template.docx
June 02, 2025 - Action Plan Worksheet
ACTION PLAN WORKSHEET
INSTRUCTIONS:
1. Discuss with your team some improvements you’d like to make specific to the High Leverage Changes listed in the table. Use the data from the Quality Improvement Change Assessment (QICA), current patient panel data, discussions with your coach and team, or ob…
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psnet.ahrq.gov/node/38033/psn-pdf
September 24, 2010 - Implementing online medication reconciliation at a large
academic medical center.
September 24, 2010
Bails D, Clayton K, Roy K, et al. Implementing online medication reconciliation at a large academic medical
center. Jt Comm J Qual Patient Saf. 2008;34(9):499-508.
https://psnet.ahrq.gov/issue/implementing-online-m…
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psnet.ahrq.gov/node/46775/psn-pdf
March 07, 2018 - Ten ERs in Colorado tried to curtail opioids and did better
than expected.
March 7, 2018
Daley J. Colorado Public Radio. February 23, 2018.
https://psnet.ahrq.gov/issue/ten-ers-colorado-tried-curtail-opioids-and-did-better-expected
Innovations in the prescribing of opioids in the emergency department are needed to…
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psnet.ahrq.gov/node/41245/psn-pdf
March 29, 2012 - The occurrence of wrong-site surgery self-reported by
candidates for certification by the American Board of
Orthopaedic Surgery.
March 29, 2012
James MA, Seiler JG, Harrast JJ, et al. The occurrence of wrong-site surgery self-reported by candidates
for certification by the American Board of Orthopaedic Surgery. J …
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psnet.ahrq.gov/node/72847/psn-pdf
March 17, 2021 - Barriers to accessing nighttime supervisors: a national
survey of internal medicine residents.
March 17, 2021
Catalanotti JS, O’Connor AB, Kisielewski M, et al. Barriers to accessing nighttime supervisors: a national
survey of internal medicine residents. J Gen Intern Med. 2021;36(7):1974-1979. doi:10.1007/s11606-0…
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psnet.ahrq.gov/node/851362/psn-pdf
July 12, 2023 - Health system resilience, accreditation, high-quality care,
and continuous quality improvement: what is the
destination and how do we get there?
July 12, 2023
Nicklin W, Greenfield D. Health system resilience, accreditation, high-quality care, and continuous quality
improvement: what is the destination and how do …
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psnet.ahrq.gov/node/47489/psn-pdf
November 21, 2018 - Impact of the Care Quality Commission on Provider
Performance: Room for Improvement?
November 21, 2018
Smithson R, Richardson E, Roberts J, et al. The King's Fund, Alliance Manchester Business School;
September 2018. ISBN: 9781909029880.
https://psnet.ahrq.gov/issue/impact-care-quality-commission-provider-performa…
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psnet.ahrq.gov/node/61115/psn-pdf
November 11, 2020 - Education initiatives in cognitive debiasing to improve
diagnostic accuracy in student providers: a scoping
review.
November 11, 2020
Griffith PB, Doherty C, Smeltzer SC, et al. Education initiatives in cognitive debiasing to improve diagnostic
accuracy in student providers: a scoping review. J Am Assoc Nurse Prac…