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  1. Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions. | PSNet

    psnet.ahrq.gov/issue/hassle-dispensary-pilot-study-proactive-risk-monitoring-tool-organisational-learning-based
    January 21, 2015 - Study Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions. Citation Text: Sujan M-A, Ingram C, McConkey T, et al. Hassle in the dispensary: pilot study of a proactive risk monitoring tool for or…

  2. Adverse drug events in a paediatric intensive care unit: a prospective cohort. | PSNet

    psnet.ahrq.gov/issue/adverse-drug-events-paediatric-intensive-care-unit-prospective-cohort
    April 24, 2018 - Study Adverse drug events in a paediatric intensive care unit: a prospective cohort. Citation Text: Silva DCB, Araujo OR, Arduini RG, et al. Adverse drug events in a paediatric intensive care unit: a prospective cohort. BMJ Open. 2013;3(2):e001868. doi:10.1136/bmjopen-2012-001868. Co…

  3. 5-Red-Light-Green-Light (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/5-red-light-green-light.docx
    June 01, 2023 - AHRQ Safety Program for Improving Surgical Care and Recovery Red Light, Green Light: An Overview of Common Implementation Barriers and Facilitators Purpose of this tool: To help team leaders identify barriers to and facilitators of implementing Improving Surgical Care and Recovery (ISCR), an enhanced recovery program…

  4. After Mid Staffordshire: from acknowledgement, through learning, to improvement. | PSNet

    psnet.ahrq.gov/issue/after-mid-staffordshire-acknowledgement-through-learning-improvement
    August 28, 2024 - Special or Theme Issue After Mid Staffordshire: from acknowledgement, through learning, to improvement. Citation Text: Martin G, Dixon-Woods M. After Mid Staffordshire: from acknowledgement, through learning, to improvement. BMJ Qual Saf. 2014;23(9):706-8. doi:10.1136/bmjqs-2014-003359. …

  5. Lack of timely follow-up of abnormal imaging results and radiologists' recommendations. | PSNet

    psnet.ahrq.gov/issue/lack-timely-follow-abnormal-imaging-results-and-radiologists-recommendations
    April 13, 2017 - Study Lack of timely follow-up of abnormal imaging results and radiologists' recommendations. Citation Text: Al-Mutairi A, Meyer AND, Chang P, et al. Lack of timely follow-up of abnormal imaging results and radiologists' recommendations. J Am Coll Radiol. 2015;12(4):385-389. doi:10.1016/…

  6. An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors. | PSNet

    psnet.ahrq.gov/issue/empirically-derived-taxonomy-factors-affecting-physicians-willingness-disclose-medical-errors
    February 15, 2011 - Review An empirically derived taxonomy of factors affecting physicians' willingness to disclose medical errors. Citation Text: Kaldjian LC, Jones EW, Rosenthal GE, et al. An empirically derived taxonomy of factors affecting physicians’ willingness to disclose medical errors. J Gen Inter…

  7. Care Coordination | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/carecoordination.html
    June 01, 2018 - Chartbook on Care Coordination Care Coordination Previous Page Next Page Table of Contents Chartbook on Care Coordination Acknowledgments Care Coordination Trends in Care Coordination Measures Transitions of Care Preventable Emergency Department Visits Potentially Avoidable Hospitalizati…

  8. Patient safety incidents caused by poor quality surgical instruments. | PSNet

    psnet.ahrq.gov/issue/patient-safety-incidents-caused-poor-quality-surgical-instruments
    April 06, 2022 - Study Patient safety incidents caused by poor quality surgical instruments. Citation Text: Dominguez ED, Rocos B. Patient Safety Incidents Caused by Poor Quality Surgical Instruments. Cureus. 2019;11(6):e4877. doi:10.7759/cureus.4877. Copy Citation Format: DOI Google Schola…

  9. 023-Optimizing-Evc-One-Pager (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/023-optimizing-evc-one-pager.docx
    October 01, 2024 - In the patient care environment, quality of cleaning is measured by which and what percentage of high-touch surfaces (HTSs) are adequately cleaned and disinfected. Below, the four most common methods of monitoring are discussed, including their pros and cons. Observation1-3 · A supervisor or trained staff conducts visu…

  10. Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries. | PSNet

    psnet.ahrq.gov/issue/implementing-electronic-root-cause-analysis-reporting-system-decrease-hospital-acquired
    December 22, 2021 - Study Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries. Citation Text: Armstrong AA. Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries. J Healthc Qual. 2023;45(3):…

  11. Using simulation to improve systems-based practices. | PSNet

    psnet.ahrq.gov/issue/using-simulation-improve-systems-based-practices
    January 22, 2016 - Review Using simulation to improve systems-based practices. Citation Text: Gardner AK, Johnston MJ, Korndorffer JR, et al. Using Simulation to Improve Systems-Based Practices. Jt Comm J Qual Patient Saf. 2017;43(9):484-491. doi:10.1016/j.jcjq.2017.05.006. Copy Citation Format: …

  12. Characteristics of patient care management problems identified in emergency department morbidity and mortality investigations during 15 years. | PSNet

    psnet.ahrq.gov/issue/characteristics-patient-care-management-problems-identified-emergency-department-morbidity
    April 24, 2018 - Study Characteristics of patient care management problems identified in emergency department morbidity and mortality investigations during 15 years. Citation Text: Cosby K, Roberts R, Palivos L, et al. Characteristics of patient care management problems identified in emergency departme…

  13. Person- and Family-Centered Care | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/nhqrdr/chartbooks/personcentered/pfcc.html
    June 01, 2018 - Chartbook on Person- and Family-Centered Care Person- and Family-Centered Care Previous Page Next Page Table of Contents Chartbook on Person- and Family-Centered Care Acknowledgments Person- and Family-Centered Care Summary of Trends Measures of Person- and Family- Centered Care Communicat…

  14. Patient safety on the otolaryngology service: the role of an established rapid response system. | PSNet

    psnet.ahrq.gov/issue/patient-safety-otolaryngology-service-role-established-rapid-response-system
    October 19, 2022 - Study Patient safety on the otolaryngology service: the role of an established rapid response system. Citation Text: Oliver CL, Devita MA, Dunwoody CJ, et al. Patient safety on the otolaryngology service: the role of an established rapid response system. Quality and Safety in Health Ca…

  15. Medication errors in neonatal and paediatric intensive-care units. | PSNet

    psnet.ahrq.gov/issue/medication-errors-neonatal-and-paediatric-intensive-care-units
    February 03, 2011 - Study Classic Medication errors in neonatal and paediatric intensive-care units. Citation Text: Raju TN, Kecskes S, Thornton JP, et al. Medication errors in neonatal and paediatric intensive-care units. Lancet. 1989;2(8659):374-6. Copy Citation Format: …

  16. CLABSI Learning From Defects Tool (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects_revised.docx
    April 01, 2022 - CLABSI Learning From Defects Tool Learn From Defects Tool Worksheet: Central Line-Associated Bloodstream Infection (CLABSI) This worksheet is designed to be used near the bedside and is the shortened version of the CLABSI Event Report Tool: Data for Event Analysis. This worksheet will help your team learn what happ…

  17. CAUTI Learning From Defects Tool (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects-revised.docx
    April 01, 2022 - CAUTI Learning From Defects Tool Learn From Defects Tool Worksheet: Catheter-Associated Urinary Tract Infection (CAUTI) This worksheet is designed to be used near the bedside and is the shortened version of the CAUTI Event Report Tool: Data for Event Analysis. This worksheet will help your team learn what happened,…

  18. QAPI Leadership Rounding Guide (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/resources/qapi-leadership-rounding-guide-centers-for-medicare.pdf
    June 02, 2025 - QAPI Leadership Rounding Guide Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance. Directions: Leadership rounding is a process where leaders (e.g., administrator, department heads, and nurse managers) are out in the building with staff and residents, t…

  19. Overview of the National Action Alliance for Patient and Workforce Safety | Agency for Healthcare Research and Quality

    www.ahrq.gov/action-alliance/overview/index.html
    October 01, 2024 - Overview of the National Action Alliance for Patient and Workforce Safety What Is the National Action Alliance? The National Action Alliance for Patient and Workforce Safety is a collective effort of federal agencies and private partners to improve the safety of patients and the healthcare workforce. Working to…

  20. Medication administration in aged care facilities: a mixed-methods systematic review. | PSNet

    psnet.ahrq.gov/issue/medication-administration-aged-care-facilities-mixed-methods-systematic-review
    March 05, 2025 - Review Medication administration in aged care facilities: a mixed-methods systematic review. Citation Text: Garratt S, Dowling A, Manias E. Medication administration in aged care facilities: a mixed‐methods systematic review. J Adv Nurs. 2025;81(2):621-640. doi:10.1111/jan.16318. Copy …
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