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psnet.ahrq.gov/node/841140/psn-pdf
December 07, 2022 - Association of measured quality and future financial
performance among hospitals performing cardiac
surgery.
December 7, 2022
Enumah SJ, Sundt TM, Chang DC. Association of measured quality and future financial performance
among hospitals performing cardiac surgery. J Healthc Manag. 2022;67(5):367-379. doi:10.1097/…
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psnet.ahrq.gov/node/35906/psn-pdf
May 27, 2011 - Error reduction in pediatric chemotherapy: computerized
order entry and failure modes and effects analysis.
May 27, 2011
Kim G, Chen AR, Arceci RJ, et al. Error reduction in pediatric chemotherapy: computerized order entry and
failure modes and effects analysis. Arch Pediatr Adolesc Med. 2006;160(5):495-8.
https:/…
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psnet.ahrq.gov/node/43798/psn-pdf
January 07, 2015 - Pharmacist-managed inpatient discharge medication
reconciliation: a combined onsite and telepharmacy
model.
January 7, 2015
Keeys C, Kalejaiye B, Skinner M, et al. Pharmacist-managed inpatient discharge medication reconciliation:
a combined onsite and telepharmacy model. Am J Health Syst Pharm. 2014;71(24):2159-66…
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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - designed in a way that you could say, “Of these components of a complex intervention, three must be implemented
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - designed in a way that you could say, “Of these components of a complex intervention, three must be implemented
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psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
July 23, 2024 - Date First Implemented
2013
Problem Addressed
Use of peripherally
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psnet.ahrq.gov/node/49850/psn-pdf
January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia
January 1, 2019
Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
The Case
A 72-year-old woman with a history of severe peripheral vascular dis…
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psnet.ahrq.gov/perspective/conversation-cindy-brach
December 27, 2019 - This is a module that can be implemented as a stand-alone program or in combination with the complete
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psnet.ahrq.gov/node/865374/psn-pdf
March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and
Challenges
March 27, 2024
Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
Introducti…
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - Add-on Case and the Missing Checklist
Citation Text:
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - Finally, we implemented TeamSTEPPS in clinical settings and conducted research on how to improve patient … more than 3500 new Master Trainers were trained by AHRQ, and these early adopters trained others and implemented
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psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - Finally, we implemented TeamSTEPPS in clinical settings and conducted research on how to improve patient … more than 3500 new Master Trainers were trained by AHRQ, and these early adopters trained others and implemented
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psnet.ahrq.gov/node/35737/psn-pdf
July 15, 2010 - Shepherding change: how the market, healthcare
providers, and public policy can deliver quality care for
the 21st century.
July 15, 2010
Kennedy P, Pronovost P. Shepherding change: how the market, healthcare providers, and public policy
can deliver quality care for the 21st century. Crit Care Med. 2006;34(3 Suppl)…
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psnet.ahrq.gov/node/37776/psn-pdf
January 31, 2011 - Barcoded medication administration: a last line of
defense.
January 31, 2011
Cescon DW, Etchells E. Barcoded medication administration: a last line of defense. JAMA.
2008;299(18):2200-2. doi:10.1001/jama.299.18.2200.
https://psnet.ahrq.gov/issue/barcoded-medication-administration-last-line-defense
Barcoding techn…
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psnet.ahrq.gov/node/39477/psn-pdf
April 28, 2010 - Effects of an adverse-drug-event alert system on cost and
quality outcomes in community hospitals.
April 28, 2010
Piontek F, Kohli R, Conlon P, et al. Effects of an adverse-drug-event alert system on cost and quality
outcomes in community hospitals. Am J Health Syst Pharm. 2010;67(8):613-20. doi:10.2146/ajhp090056.…
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psnet.ahrq.gov/node/37997/psn-pdf
June 16, 2011 - Revealing and resolving patient safety defects: the impact
of leadership WalkRounds on frontline caregiver
assessments of patient safety.
June 16, 2011
Frankel A, Grillo SP, Pittman M, et al. Revealing and resolving patient safety defects: the impact of
leadership WalkRounds on frontline caregiver assessments of p…
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psnet.ahrq.gov/node/867640/psn-pdf
February 26, 2025 - Patient safety of virtual primary care: a qualitative study
examining risks and mitigation strategies.
February 26, 2025
Lounsbury O, Li E, Lunova T, et al. Patient safety of virtual primary care: a qualitative study examining risks
and mitigation strategies. Health Policy Tech. 2025;14(1):100966. doi:10.1016/j.hlp…
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psnet.ahrq.gov/node/39525/psn-pdf
March 13, 2019 - Effect of bar-code technology on the safety of medication
administration.
March 13, 2019
Poon EG, Keohane C, Yoon CS, et al. Effect of bar-code technology on the safety of medication
administration. New Engl J Med. 2010;362(18):1698-1707. doi:10.1056/NEJMsa0907115.
https://psnet.ahrq.gov/issue/effect-bar-code-tech…
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psnet.ahrq.gov/node/44189/psn-pdf
September 09, 2015 - Variation in printed handoff documents: results and
recommendations from a multicenter needs assessment.
September 9, 2015
Rosenbluth G, Bale JF, Starmer AJ, et al. Variation in printed handoff documents: Results and
recommendations from a multicenter needs assessment. J Hosp Med. 2015;10(8):517-24.
doi:10.1002/jh…
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psnet.ahrq.gov/node/36460/psn-pdf
May 27, 2011 - Medication errors related to computerized order entry for
children.
May 27, 2011
Walsh KE, Adams WG, Bauchner H, et al. Medication errors related to computerized order entry for
children. Pediatrics. 2006;118(5):1872-1879.
https://psnet.ahrq.gov/issue/medication-errors-related-computerized-order-entry-children
Th…