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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit2-8.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 2.8. Lean Team Training at Central Hospital
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Case 2.…
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psnet.ahrq.gov/node/33962/psn-pdf
June 22, 2007 - Enacting the Washington state patient safety act requiring
hospital staffing plans for nursing services and
establishing recordkeeping and reporting requirements.
June 22, 2007
HB 1602. Washington State Legislature. 2003-2004.
https://psnet.ahrq.gov/issue/enacting-washington-state-patient-safety-act-requiring-hosp…
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psnet.ahrq.gov/node/37836/psn-pdf
September 25, 2008 - Staff attitudes about event reporting and patient safety
culture in hospital transfusion services.
September 25, 2008
Sorra J, Nieva V, Fastman BR, et al. Staff attitudes about event reporting and patient safety culture in
hospital transfusion services. Transfusion (Paris). 2008;48(9):1934-42. doi:10.1111/j.1537-
…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-16.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 3.16. Project Team Composition–Cardiology Follow-up Appointment Scheduling
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1…
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psnet.ahrq.gov/node/39933/psn-pdf
December 31, 2014 - Assessing the accuracy of drug profiles in an electronic
medical record system of a Washington State hospital.
December 31, 2014
Platte B, Akinci F, Güç Y. Assessing the accuracy of drug profiles in an electronic medical record system of
a Washington state hospital. Am J Manag Care. 2010;16(10):e245-50.
https://ps…
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psnet.ahrq.gov/node/35186/psn-pdf
July 13, 2005 - Saving lives: hospitals have signed on to a six-part plan
to avoid a multitude of unnecessary deaths.
July 13, 2005
Comarow A. US News & World Report. July 2005
https://psnet.ahrq.gov/issue/saving-lives-hospitals-have-signed-six-part-plan-avoid-multitude-unnecessary-
deaths
This article, accompanying the widely r…
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psnet.ahrq.gov/node/42825/psn-pdf
December 18, 2013 - Primary care physician communication at hospital
discharge reduces medication discrepancies.
December 18, 2013
Lindquist LA, Yamahiro A, Garrett A, et al. Primary care physician communication at hospital discharge
reduces medication discrepancies. J Hosp Med. 2013;8(12):672-7. doi:10.1002/jhm.2098.
https://psnet.a…
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psnet.ahrq.gov/node/38112/psn-pdf
December 30, 2014 - Preparing your hospital for compliance with The Joint
Commission's National Patient Safety Goals.
December 30, 2014
Murdaugh L, Jordin R. Preparing your hospital for compliance with The Joint Commission's National Patient
Safety Goals. Hosp Pharm. 2010;43(9):728-733. doi:10.1310/hpj4309-728.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/41649/psn-pdf
December 21, 2014 - Last orders: follow-up of tests ordered on the day of
hospital discharge.
December 21, 2014
Ong M-S, Magrabi F, Jones G, et al. Last Orders: Follow-up of Tests Ordered on the Day of Hospital
Discharge. Arch Intern Med. 2012;172(17):1347-9. doi:10.1001/archinternmed.2012.2836.
https://psnet.ahrq.gov/issue/last-orde…
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psnet.ahrq.gov/node/41498/psn-pdf
December 31, 2014 - Standard practices for computerized clinical decision
support in community hospitals: a national survey.
December 31, 2014
Ash JS, McCormack JL, Sittig DF, et al. Standard practices for computerized clinical decision support in
community hospitals: a national survey. J Am Med Inform Assoc. 2012;19(6):980-7. doi:10.…
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psnet.ahrq.gov/node/37401/psn-pdf
March 28, 2012 - Interventions for preventing falls in acute- and chronic-
care hospitals: a systematic review and meta-analysis.
March 28, 2012
Coussement J, De Paepe L, Schwendimann R, et al. Interventions for preventing falls in acute- and
chronic-care hospitals: a systematic review and meta-analysis. J Am Geriatr Soc. 2008;56(1…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0217-section-6-tables-6-7.pdf
June 02, 2025 - Section 6, Tables 6 and 7
Table 6: Agreement and Kappa Statistics for Inter‐Rater Reliability at Three Sites
Site Measure Numerator/
Eligibility Criteria
Number of Records Reviewed N Agreed (%) Kappa Statistic
Hospital #1 Pain Numerator 3 100% 1.00
Pain Criterion 3 100% 1.00
Hospital #2 Pain Numerator …
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psnet.ahrq.gov/node/74009/psn-pdf
October 27, 2021 - Quantifying discharge medication reconciliation errors at
2 pediatric hospitals.
October 27, 2021
Morse KE, Chadwick WA, Paul W, et al. Quantifying discharge medication reconciliation errors at 2
pediatric hospitals. Pediatr Qual Saf. 2021;6(4):e436. doi:10.1097/pq9.0000000000000436.
https://psnet.ahrq.gov/issue/q…
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psnet.ahrq.gov/node/38276/psn-pdf
December 10, 2008 - Addressing delays in medication administration for
patients transferred from the hospital to the nursing
home: a pilot quality improvement project.
December 10, 2008
Ward KT, Bates-Jensen B, Eslami MS, et al. Addressing delays in medication administration for patients
transferred from the hospital to the nursing h…
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psnet.ahrq.gov/node/40911/psn-pdf
November 09, 2011 - Preventable and non-preventable adverse drug events in
hospitalized patients: a prospective chart review in the
Netherlands.
November 9, 2011
Dequito AB, Mol PGM, van Doormaal J, et al. Preventable and non-preventable adverse drug events in
hospitalized patients: a prospective chart review in the Netherlands. Drug…
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psnet.ahrq.gov/node/35583/psn-pdf
June 17, 2010 - Using a bar-coded medication administration system to
prevent medication errors in a community hospital
network.
June 17, 2010
Sakowski J, Leonard T, Colburn S, et al. Using a bar-coded medication administration system to prevent
medication errors in a community hospital network. American Journal of Health-System …
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psnet.ahrq.gov/node/35043/psn-pdf
June 22, 2009 - Human factors engineering: a tool for medical device
evaluation in hospital procurement decision-making.
June 22, 2009
Ginsburg G. Human factors engineering: a tool for medical device evaluation in hospital procurement
decision-making. J Biomed Inform. 2005;38(3):213-9.
https://psnet.ahrq.gov/issue/human-factors-e…
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psnet.ahrq.gov/node/34960/psn-pdf
June 22, 2009 - Making hospital care safer and better: the structure-
process connection leading to adverse events.
June 22, 2009
El-Jardali F, Lagacé M. Making hospital care safer and better: the structure-process connection leading to
adverse events. Healthc Q. 2005;8(2):40-8.
https://psnet.ahrq.gov/issue/making-hospital-care-s…
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psnet.ahrq.gov/node/50625/psn-pdf
November 06, 2019 - Pediatric medication safety considerations for
pharmacists in an adult hospital setting.
November 6, 2019
Kennedy AR, Massey LR. Pediatric medication safety considerations for pharmacists in an adult hospital
setting. Am J Health Syst Pharm. 2019;76(19):1481-1491. doi:10.1093/ajhp/zxz168.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/35760/psn-pdf
July 19, 2010 - Achieving rapid door-to-balloon times: how top hospitals
improve complex clinical systems.
July 19, 2010
Bradley EH, Curry LA, Webster TR, et al. Achieving rapid door-to-balloon times: how top hospitals improve
complex clinical systems. Circulation. 2006;113(8):1079-85.
https://psnet.ahrq.gov/issue/achieving-rapid…