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Improvement Tools | PSNet

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February 26, 2025 - Improvement Resources Overview Patient Safety Innovations highlight important innovations that can lead to improvements in patient safety, while Toolkits provide the practical applications of PSNet research and concepts for front line providers to use in their day to day work. Together these support the implementatio…

The role of the non-ICU staff nurse on a medical emergency team: perceptions and understanding. | PSNet

psnet.ahrq.gov/issue/role-non-icu-staff-nurse-medical-emergency-team-perceptions-and-understanding

April 12, 2006 - Study The role of the non-ICU staff nurse on a medical emergency team: perceptions and understanding. Citation Text: The role of the non-ICU staff nurse on a medical emergency team: perceptions and understanding. Pusateri ME; Prior MM; Kiely SC. Copy Citation Save …

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. | PSNet

psnet.ahrq.gov/issue/what-works-medication-reconciliation-treatment-and-site-analysis-marquis2-study

May 19, 2021 - Study What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. Citation Text: Schnipper JL, Reyes Nieva H, Yoon CS, et al. What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. BMJ Qual Saf. 2023;32(8):4…

Enhancing patient safety and risk management through clinical pathways in oncology. | PSNet

psnet.ahrq.gov/issue/enhancing-patient-safety-and-risk-management-through-clinical-pathways-oncology

September 13, 2023 - Study Enhancing patient safety and risk management through clinical pathways in oncology. Citation Text: Milanesi M, Fiorito R, Caloccia L, et al. Enhancing patient safety and risk management through clinical pathways in oncology. BMJ Open Qual. 2025;14(1):e003012. doi:10.1136/bmjoq-2024…

Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for veterans — Los Angeles, California, 2020. | PSNet

psnet.ahrq.gov/issue/universal-and-serial-laboratory-testing-sars-cov-2-long-term-care-skilled-nursing-facility

November 16, 2022 - Commentary Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skilled nursing facility for veterans — Los Angeles, California, 2020. Citation Text: Dora AV, Winnett A, Jatt LP, et al. Universal and serial laboratory testing for SARS-CoV-2 at a long-term care skill…

Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation. | PSNet

psnet.ahrq.gov/issue/usability-human-factors-based-clinical-decision-support-emergency-department-lessons-learned

January 08, 2020 - Study Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation. Citation Text: Salwei ME, Hoonakker PLT, Carayon P, et al. Usability of a human factors-based clinical decision support in the emergency departme…

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations. | PSNet

psnet.ahrq.gov/issue/why-patient-summaries-electronic-health-records-do-not-provide-cognitive-support-necessary

January 18, 2013 - Study Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations. Citation Text: Staggers N, Clark L, Blaz JW, et al. Why patient summaries in electronic…

Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis. | PSNet

psnet.ahrq.gov/issue/association-implementation-and-social-network-factors-patient-safety-culture-medical-homes

September 28, 2022 - Study Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis. Citation Text: Dy SM, Acton RM, Yuan CT, et al. Association of implementation and social network factors with patient safety culture in medical homes: a co…

Implementing situation-background-assessment-recommendation in an anaesthetic clinic and subsequent information retention among receivers: a prospective interventional study of postoperative handovers. | PSNet

psnet.ahrq.gov/issue/implementing-situation-background-assessment-recommendation-anaesthetic-clinic-and-subsequent

December 30, 2014 - Study Implementing situation-background-assessment-recommendation in an anaesthetic clinic and subsequent information retention among receivers: a prospective interventional study of postoperative handovers. Citation Text: Randmaa M, Swenne CL, Mårtensson G, et al. Implementing situation…

Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies. | PSNet

psnet.ahrq.gov/issue/implementing-national-program-reduce-catheter-associated-urinary-tract-infection-quality

June 08, 2016 - Study Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies. Citation Text: Fakih MG, George C, Edson B, et al.…

Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. | PSNet

psnet.ahrq.gov/issue/reduction-medication-errors-hospitals-due-adoption-computerized-provider-order-entry-systems

June 13, 2018 - Review Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Citation Text: Radley DC, Wasserman MR, Olsho LE, et al. Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. J Am Med Inf…

A checklist-based intervention to improve surgical outcomes in Michigan: evaluation of the Keystone Surgery program. | PSNet

psnet.ahrq.gov/issue/checklist-based-intervention-improve-surgical-outcomes-michigan-evaluation-keystone-surgery

May 01, 2015 - Study Classic A checklist-based intervention to improve surgical outcomes in Michigan: evaluation of the Keystone Surgery program. Citation Text: Reames BN, Krell RW, Campbell D, et al. A checklist-based intervention to improve surgical outcomes in Michigan: eva…

Addressing veteran health-related social needs: how Joint Commission standards accelerated integration and expansion of tools and services in the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/addressing-veteran-health-related-social-needs-how-joint-commission-standards-accelerated

November 24, 2021 - Commentary Addressing veteran health-related social needs: how Joint Commission standards accelerated integration and expansion of tools and services in the Veterans Health Administration. Citation Text: List JM, Russell LE, Hausmann LRM, et al. Addressing veteran health-related social n…

Physician attitudes toward family-activated medical emergency teams for hospitalized children. | PSNet

psnet.ahrq.gov/issue/physician-attitudes-toward-family-activated-medical-emergency-teams-hospitalized-children

April 06, 2012 - Study Physician attitudes toward family-activated medical emergency teams for hospitalized children. Citation Text: Paciotti B, Roberts KE, Tibbetts KM, et al. Physician attitudes toward family-activated medical emergency teams for hospitalized children. Jt Comm J Qual Patient Saf. 2014;…

Frequency of failure to inform patients of clinically significant outpatient test results. | PSNet

psnet.ahrq.gov/issue/frequency-failure-inform-patients-clinically-significant-outpatient-test-results

April 24, 2018 - Study Frequency of failure to inform patients of clinically significant outpatient test results. Citation Text: Casalino LP, Dunham D, Chin MH, et al. Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med. 2009;169(12):1123-9. doi:10…

Informatics tools in deprescribing and medication optimization in older adults: development and dissemination of VIONE methodology in a high reliability organization. | PSNet

psnet.ahrq.gov/issue/informatics-tools-deprescribing-and-medication-optimization-older-adults-development-and

February 05, 2020 - Study Informatics tools in deprescribing and medication optimization in older adults: development and dissemination of VIONE methodology in a high reliability organization. Citation Text: Winter SG, Sedgwick C, Wallace-Lacey A, et al. Informatics tools in deprescribing and medication opt…

Impact of automated alerts on discharge opioid overprescribing after general surgery. | PSNet

psnet.ahrq.gov/issue/impact-automated-alerts-discharge-opioid-overprescribing-after-general-surgery

September 29, 2017 - Study Impact of automated alerts on discharge opioid overprescribing after general surgery. Citation Text: Rizk E, Kaur N, Duong PY, et al. Impact of automated alerts on discharge opioid overprescribing after general surgery. Am J Health Syst Pharm. 2024;81(24):1288-1296. doi:10.1093/ajh…

Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. | PSNet

psnet.ahrq.gov/issue/making-inpatient-medication-reconciliation-patient-centered-clinically-relevant-and

January 14, 2009 - Commentary Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. Citation Text: Greenwald JL, Halasyamani L, Greene J, et al. Making inpatient medication reconciliation pati…

Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. | PSNet

psnet.ahrq.gov/issue/effects-online-personal-health-record-medication-accuracy-and-safety-cluster-randomized-trial

March 04, 2015 - Study Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. Citation Text: Schnipper JL, Gandhi TK, Wald JS, et al. Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. J Am Med Inf…

Using a potentially aggressive/violent patient huddle to improve health care safety. | PSNet

psnet.ahrq.gov/issue/using-potentially-aggressiveviolent-patient-huddle-improve-health-care-safety

November 16, 2022 - Commentary Using a potentially aggressive/violent patient huddle to improve health care safety. Citation Text: Larson LA, Finley JL, Gross TL, et al. Using a Potentially Aggressive/Violent Patient Huddle to Improve Health Care Safety. Jt Comm J Qual Patient Saf. 2019;45(2):74-80. doi:10.…

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