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psnet.ahrq.gov/issue/improving-handoffs-perioperative-environment-conceptual-framework-key-theories-system-factors
November 16, 2022 - Commentary
Improving handoffs in the perioperative environment: a conceptual framework of key theories, system factors, methods, and core interventions to ensure success.
Citation Text:
Starmer AJ, Michael MM, Spector ND, et al. Improving handoffs in the perioperative environment: a conc…
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psnet.ahrq.gov/issue/implementing-48-h-ewtd-compliant-rota-junior-doctors-uk-does-not-compromise-patients-safety
June 26, 2019 - Study
Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients' safety: assessor-blind pilot comparison.
Citation Text:
Cappuccio FP, Bakewell A, Taggart FM, et al. Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not co…
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psnet.ahrq.gov/issue/communication-failure-operating-room
February 25, 2009 - Study
Communication failure in the operating room.
Citation Text:
Halverson AL, Casey JT, Andersson J, et al. Communication failure in the operating room. Surgery. 2011;149(3):305-310. doi:10.1016/j.surg.2010.07.051.
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psnet.ahrq.gov/issue/high-5s-initiative-implementation-medication-reconciliation-france-5-years-experimentation
August 04, 2021 - Commentary
High 5s initiative: implementation of medication reconciliation in France a 5 years experimentation.
Citation Text:
Dufay É, Doerper S, Michel B, et al. High 5s initiative: implementation of medication reconciliation in France a 5 years experimentation. Safety in Health. 2017;…
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psnet.ahrq.gov/issue/assessment-opioid-prescribing-practices-and-after-implementation-health-system-intervention
November 16, 2022 - Study
Emerging Classic
Assessment of opioid prescribing practices before and after implementation of a health system intervention to reduce opioid overprescribing.
Citation Text:
Meisenberg BR, Grover J, Campbell C, et al. Assessment of Opioid Prescribing Practi…
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psnet.ahrq.gov/issue/standardizing-medication-reconciliation-pediatric-emergency-department
March 10, 2019 - Study
Standardizing medication reconciliation in a pediatric emergency department.
Citation Text:
Sheth S, Bialostozky M, Hollenbach K, et al. Standardizing medication reconciliation in a pediatric emergency department. Pediatrics. 2024;153(2):e2023061964. doi:10.1542/peds.2023-061964.
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psnet.ahrq.gov/issue/patient-safety-leadership-walkroundstm-partners-healthcare-learning-implementation
January 04, 2017 - Study
Patient Safety Leadership WalkRounds™ at Partners HealthCare: learning from implementation.
Citation Text:
Frankel A, Grillo SP, Baker EG, et al. Patient Safety Leadership WalkRounds at Partners Healthcare: learning from implementation. Jt Comm J Qual Patient Saf. 2005;31(8):423-37…
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psnet.ahrq.gov/issue/improving-bar-coded-medication-administration-system-department-veterans-affairs
November 18, 2009 - Study
Improving the bar-coded medication administration system at the Department of Veterans Affairs.
Citation Text:
Mills PD, Neily J, Mims E, et al. Improving the bar-coded medication administration system at the Department of Veterans Affairs. Am J Health Syst Pharm. 2006;63(15):144…
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psnet.ahrq.gov/issue/blueprint-success-implementation-center-medicare-and-medicaid-services-mandated
September 09, 2020 - Commentary
A blueprint for success: implementation of the Center for Medicare and Medicaid Services mandated anesthesiology oversight for procedural sedation in a large health system.
Citation Text:
Abdelmalak BB, Adhami T, Simmons W, et al. A blueprint for success: implementation of the…
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psnet.ahrq.gov/issue/evaluating-implementation-project-re-engineered-discharge-red-five-veterans-health
June 26, 2024 - Study
Evaluating the implementation of Project Re-Engineered Discharge (RED) in five Veterans Health Administration (VHA) hospitals.
Citation Text:
Sullivan JL, Shin MH, Engle RL, et al. Evaluating the Implementation of Project Re-Engineered Discharge (RED) in Five Veterans Health Admini…
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psnet.ahrq.gov/issue/effects-night-team-system-resident-sleep-and-work-hours
November 16, 2022 - Study
Effects of a night-team system on resident sleep and work hours.
Citation Text:
Chua K-P, Gordon M, Sectish TC, et al. Effects of a night-team system on resident sleep and work hours. Pediatrics. 2011;128(6):1142-7. doi:10.1542/peds.2011-1049.
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psnet.ahrq.gov/issue/results-enhanced-clinic-handoff-and-resident-education-resident-patient-ownership-and-patient
March 28, 2018 - Study
Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety.
Citation Text:
Pincavage A, Dahlstrom M, Prochaska M, et al. Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety.…
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psnet.ahrq.gov/issue/contamination-health-care-personnel-during-removal-personal-protective-equipment
April 24, 2018 - Study
Contamination of health care personnel during removal of personal protective equipment.
Citation Text:
Tomas ME, Kundrapu S, Thota P, et al. Contamination of Health Care Personnel During Removal of Personal Protective Equipment. JAMA Intern Med. 2015;175(12):1904-10. doi:10.1001/ja…
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psnet.ahrq.gov/issue/sustainable-effective-implementation-surgical-preprocedural-checklist-attestation-format-all
July 31, 2013 - Study
Sustainable, effective implementation of a surgical preprocedural checklist: an "attestation" format for all operating team members.
Citation Text:
Porter AJ, Narimasu JY, Mulroy MF, et al. Sustainable, effective implementation of a surgical preprocedural checklist: an "attestati…
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psnet.ahrq.gov/issue/minimizing-opioid-prescribing-surgery-mopis-initiative-analysis-implementation-barriers
September 09, 2020 - Study
Minimizing Opioid Prescribing in Surgery (MOPiS) initiative: an analysis of implementation barriers.
Citation Text:
Coughlin JM, Shallcross ML, Schäfer WLA, et al. Minimizing Opioid Prescribing in Surgery (MOPiS) Initiative: An Analysis of Implementation Barriers. J Surg Res. 2019;…
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psnet.ahrq.gov/issue/relationship-between-hospital-patient-safety-culture-and-performance-centers-medicare
December 11, 2024 - Study
The relationship between hospital patient safety culture and performance on Centers for Medicare & Medicaid Services value-based purchasing metrics.
Citation Text:
Noghrehchi P, Hefner JL, Walker DM. The relationship between hospital patient safety culture and performance on Center…
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psnet.ahrq.gov/node/46169/psn-pdf
June 07, 2017 - associations-between-hospital-characteristics-measure-reporting-and-centers-
medicare-medicaid
The Centers for Medicare and Medicaid Services (CMS) recently implemented
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psnet.ahrq.gov/node/37942/psn-pdf
May 04, 2014 - improving-handoff-communications-critical-care-utilizing-simulation-based-
training-toward
Simulation training is being widely implemented
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psnet.ahrq.gov/node/41437/psn-pdf
January 03, 2017 - This study implemented bedside
nursing handoffs at shift change as a patient-centered approach to reducing
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psnet.ahrq.gov/node/41116/psn-pdf
May 24, 2012 - The authors found that hospitals that had fully implemented the safe practices had a lower
incidence