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psnet.ahrq.gov/node/836926/psn-pdf
April 13, 2022 - Overall performance of a drug-drug interaction clinical
decision support system: quantitative evaluation and end-
user survey.
April 13, 2022
Van De Sijpe G, Quintens C, Walgraeve K, et al. Overall performance of a drug–drug interaction clinical
decision support system: quantitative evaluation and end-user survey.…
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psnet.ahrq.gov/node/50773/psn-pdf
January 08, 2020 - Effect of cognitive aids on adherence to best practice in
the treatment of deteriorating surgical patients: a
randomized clinical trial in a simulation setting.
January 8, 2020
Koers L, van Haperen M, Meijer CGF, et al. Effect of Cognitive Aids on Adherence to Best Practice in the
Treatment of Deteriorating Surgic…
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psnet.ahrq.gov/node/42619/psn-pdf
January 23, 2019 - High-reliability health care: getting there from here.
January 23, 2019
Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91(3):459-490.
doi:10.1111/1468-0009.12023.
https://psnet.ahrq.gov/issue/high-reliability-health-care-getting-there-here
Aviation is often cited as an …
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psnet.ahrq.gov/node/866189/psn-pdf
June 26, 2024 - Listen to me, I really am sick! Patient and family
narratives of clinical deterioration before and during rapid
response system intervention.
June 26, 2024
Bucknall TK, Guinane J, McCormack B, et al. Listen to me, I really am sick! Patient and family narratives of
clinical deterioration before and during rapid res…
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psnet.ahrq.gov/node/46309/psn-pdf
December 22, 2018 - Effects of the I-PASS nursing handoff bundle on
communication quality and workflow.
December 22, 2018
Starmer AJ, Schnock KO, Lyons A, et al. Effects of the I-PASS Nursing Handoff Bundle on communication
quality and workflow. BMJ Qual Saf. 2017;26(12):949-957. doi:10.1136/bmjqs-2016-006224.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/837210/psn-pdf
May 25, 2022 - A learning health system agenda for organizational
approaches to enhancing occupational well-being among
clinicians.
May 25, 2022
Rotenstein LS, Melnick ER, Sinsky CA. A learning health system agenda for organizational approaches to
enhancing occupational well-being among clinicians. JAMA. 2022;327(21):2079-2080.
…
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psnet.ahrq.gov/node/837795/psn-pdf
August 10, 2022 - Role of the regulator in enabling a just culture: a
qualitative study in mental health and hospital care.
August 10, 2022
Weenink J-W, Wallenburg I, Hartman L, et al. Role of the regulator in enabling a just culture: a qualitative
study in mental health and hospital care. BMJ Open. 2022;12(7):e061321. doi:10.1136/b…
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psnet.ahrq.gov/node/45708/psn-pdf
October 31, 2017 - Development and preliminary testing of the Coordination
Process Error Reporting Tool (CPERT), a prospective
clinical surveillance mechanism for teamwork errors in
the pediatric cardiac ICU.
October 31, 2017
Bates KE, Shea JA, Bird GL, et al. Development and Preliminary Testing of the Coordination Process Error
Re…
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psnet.ahrq.gov/node/47382/psn-pdf
August 29, 2018 - Parenteral opioid shortage—treating pain during the
opioid-overdose epidemic.
August 29, 2018
Bruera E. Parenteral Opioid Shortage - Treating Pain during the Opioid-Overdose Epidemic. N Engl J Med.
2018;379(7):601-603. doi:10.1056/NEJMp1807117.
https://psnet.ahrq.gov/issue/parenteral-opioid-shortage-treating-pain-…
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psnet.ahrq.gov/node/46024/psn-pdf
June 15, 2017 - Introductions during time-outs: do surgical team
members know one another's names?
June 15, 2017
Birnbach DJ, Rosen LF, Fitzpatrick M, et al. Introductions during time-outs: do surgical team members
know one another's names? Jt Comm J Qual Patient Saf. 2017;43(6):284-288.
doi:10.1016/j.jcjq.2017.03.001.
https://p…
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psnet.ahrq.gov/node/72521/psn-pdf
December 02, 2020 - I-PASS illness diversity identifies patients at risk for
overnight clinical deterioration.
December 2, 2020
Shah C, Sanber K, Jacobson R, et al. I-PASS illness diversity identifies patients at risk for overnight clinical
deterioration. J Grad Med Educ. 2020;12(5):578-582. doi:10.4300/jgme-d-19-00755.1.
https://psn…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/staff-safety-asst.docx
January 01, 2017 - Tool: SSA
What Is the Purpose of This Tool?
The purpose of this tool is to tap into frontline knowledge to find risks on your unit that impact patient safety.
Who Should Use This Tool?
All health care providers and administrative staff on the unit should use this tool.
When Should This Tool Be Used?
Assessing saf…
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psnet.ahrq.gov/node/45350/psn-pdf
October 21, 2016 - A National Trauma Care System: Integrating Military and
Civilian Trauma Systems to Achieve Zero Preventable
Deaths After Injury.
October 21, 2016
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press;
2016.
https://psnet.ahrq.gov/issue/national-trauma-care-system-inte…
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psnet.ahrq.gov/node/837640/psn-pdf
July 06, 2022 - Identifying and reconciling patients' allergy information
within the electronic health record.
July 6, 2022
Vallamkonda S, Ortega CA, Lo YC, et al. Identifying and reconciling patients' allergy information within the
electronic health record. Stud Health Technol Inform. 2022;290:120-124. doi:10.3233/shti220044.
ht…
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psnet.ahrq.gov/node/36237/psn-pdf
September 12, 2011 - An empirically derived taxonomy of factors affecting
physicians' willingness to disclose medical errors.
September 12, 2011
Kaldjian LC, Jones EW, Rosenthal GE, et al. An empirically derived taxonomy of factors affecting
physicians’ willingness to disclose medical errors. J Gen Intern Med. 2007;21(9). doi:10.1007/b…
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psnet.ahrq.gov/node/43709/psn-pdf
December 04, 2014 - A team-based approach to reducing cardiac monitor
alarms.
December 4, 2014
Dandoy CE, Davies SM, Flesch L, et al. A team-based approach to reducing cardiac monitor alarms.
Pediatrics. 2014;134(6):e1686-e1694. doi:10.1542/peds.2014-1162.
https://psnet.ahrq.gov/issue/team-based-approach-reducing-cardiac-monitor-alar…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/handouts/staff-mupirocin.pdf
March 01, 2022 - MRSA Carriers With Devices: Prevent Infections During the Hospital Stay How To Apply Nasal Mupirocin
AHRQ Pub. No. 20(22)-0036
March 2022
STAFF MRSA Carriers With Devices: Prevent Infections During the Hospital Stay
How To Apply Nasal Mupirocin
Apply nasal mupirocin ointment twice daily for 5 days…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/handouts/staff-mupirocin.docx
March 01, 2022 - Nasal Mupirocin
MRSA Carriers With Devices: Prevent Infections During the Hospital Stay STAFFSection 10-4
How To Apply Nasal Mupirocin
AHRQ Pub. No. 20(22)-0036
March 2022
Apply nasal mupirocin ointment twice daily for 5 days to all adult non-ICU patients with medical devices (e.g., central lines, midline c…
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psnet.ahrq.gov/node/47598/psn-pdf
November 28, 2018 - Assessment of patient medication adherence, medical
record accuracy, and medication blood concentrations for
prescription and over-the-counter medications.
November 28, 2018
Sutherland JJ, Morrison RD, McNaughton CD, et al. Assessment of Patient Medication Adherence, Medical
Record Accuracy, and Medication Blood C…
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psnet.ahrq.gov/node/44590/psn-pdf
November 11, 2015 - Physician motivation: listening to what pay-for-
performance programs and quality improvement
collaboratives are telling us.
November 11, 2015
Herzer KR, Pronovost P. Physician Motivation: Listening to What Pay-for-Performance Programs and
Quality Improvement Collaboratives Are Telling Us. Jt Comm J Qual Patient S…