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psnet.ahrq.gov/node/837038/psn-pdf
May 04, 2022 - Mind the Implementation Gap. The Persistence of
Avoidable Harm in the NHS.
May 4, 2022
London UK: Patient Safety Learning: 2022.
https://psnet.ahrq.gov/issue/mind-implementation-gap-persistence-avoidable-harm-nhs
Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financi…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Improving Care Delivery Through Lean: Implementation Case Studies
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Health…
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psnet.ahrq.gov/node/45619/psn-pdf
August 16, 2017 - Checking the lists: a systematic review of electronic
checklist use in health care.
August 16, 2017
Kramer HS, Drews FA. Checking the lists: A systematic review of electronic checklist use in health care. J
Biomed Inform. 2017;71S:S6-S12. doi:10.1016/j.jbi.2016.09.006.
https://psnet.ahrq.gov/issue/checking-lists-s…
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psnet.ahrq.gov/node/73249/psn-pdf
May 12, 2021 - I-PASS handover system: a decade of evidence demands
action.
May 12, 2021
Shahian DM. I-PASS handover system: a decade of evidence demands action. BMJ Qual Saf.
2021;30(10):769-774. doi:10.1136/bmjqs-2021-013314.
https://psnet.ahrq.gov/issue/i-pass-handover-system-decade-evidence-demands-action
The I-PASS structu…
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digital.ahrq.gov/ahrq-funded-projects/patient-centered-outcomes-research-clinical-decision-support-cds-connect/citation/cds-artifact-enhancement
January 01, 2023 - Factors to consider in managing chronic pain: a pain management summary - CDS artifact enhancement based on pilot implementation.
Citation
The MITRE Corporation. Factors to consider in managing chronic pain: a pain management summary - CDS artifact enhancement based on pilot implementation. Prepared …
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digital.ahrq.gov/ahrq-funded-projects/implementing-breast-reconstruction-decision-support-tool-diverse-practice/citation/randomized
January 01, 2024 - A randomized controlled trial of the implementation of BREASTChoice, a multilevel breast reconstruction decision support tool with personalized risk prediction.
Citation
Politi MC, Myckatyn TM, Cooksey K, Olsen MA, Smith RM, Foraker R, Parrish K, Phommasathit C, Brock G, Janse S, Guglielmino J, Peled …
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www.ahrq.gov/action-alliance/webinars/safer-guides.html
February 01, 2025 - National Action Alliance Webinar: Engineering Safety Into Practice Through Implementation of the 2025 SAFER Guides
Summary On January 21, 2025, Dean Sittig, Ph.D., and Hardeep Singh, M.D., M.P.H., the authors of the Safety Assurance Factors for EHR Resilience (SAFER) Guides, discussed the development of the lat…
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digital.ahrq.gov/ahrq-funded-projects/dissemination-and-implementation-qt-risk-clinical-decision-support/final-report
January 01, 2023 - Dissemination and Implementation of QT Risk Clinical Decision Support - Final Report
Citation
Malone D. Dissemination and Implementation of QT Risk Clinical Decision Support - Final Report. (Prepared by the University of Utah under Grant No. R18 HS026662). Rockville, MD: Agency for Healthcare Research…
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digital.ahrq.gov/ahrq-funded-projects/expansion-implementation-evaluation-electronic-health-record-integrated-patient/citation/tracking
January 01, 2023 - Tracking dynamic changes in implementation strategies over time within a hybrid type 2 trial of an electronic patient-reported oncology symptom and needs monitoring program.
Citation
Smith JD, Merle JL, Webster KA, Cahue S, Penedo FJ, Garcia SF. Tracking dynamic changes in implementation strategies ov…
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digital.ahrq.gov/ahrq-funded-projects/implementation-electronic-health-screening-primary-care-improve-sti-testing/final-report
January 01, 2023 - Implementation of Electronic Health Screening in Primary Care to Improve STI Testing - Final Report
Citation
Ahmad F. Implementation of Electronic Health Screening in Primary Care to Improve STI Testing – Final Report. (Prepared by Washington University under Grant No. R18 HS026704). Rockville, MD: Ag…
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psnet.ahrq.gov/node/42903/psn-pdf
September 29, 2017 - How policy makers can smooth the way for
communication-and-resolution programs.
September 29, 2017
Sage WM, Gallagher TH, Armstrong S, et al. How policy makers can smooth the way for communication-
and- resolution programs. Health Aff (Millwood). 2014;33(1):11-9. doi:10.1377/hlthaff.2013.0930.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/37116/psn-pdf
October 04, 2011 - Adopting National Quality Forum medication safe
practices: progress and barriers to hospital
implementation.
October 4, 2011
Rask KJ, Culler SD, Scott T, et al. Adopting National Quality Forum medication safe practices: Progress
and barriers to hospital implementation. J Hosp Med. 2007;2(4). doi:10.1002/jhm.187.
…
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psnet.ahrq.gov/node/866072/psn-pdf
June 05, 2024 - WHO Global Report on Patient Safety.
June 5, 2024
Geneva, Switzerland: World Health Organization; 2024. ISBN 9789240095458.
https://psnet.ahrq.gov/issue/who-global-report-patient-safety
Comparative data can help to inform and motivate patient safety improvement efforts. This report uses the
seven objectives of the…
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psnet.ahrq.gov/node/38474/psn-pdf
March 10, 2011 - Using computerized provider order entry and clinical
decision support to improve referring physicians'
implementation of consultants' medical
recommendations.
March 10, 2011
Were MC, Abernathy G, Hui SL, et al. Using computerized provider order entry and clinical decision
support to improve referring physicians' …
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digital.ahrq.gov/ahrq-funded-projects/human-factors-considerations-design-and-implementation-telemedicine-integrated/final-report
January 01, 2023 - Human Factors Considerations in the Design and Implementation of Telemedicine Integrated Ambulance-Based Environments for Stroke Care - Final Report
Citation
Madathil K. Human Factors Considerations in the Design and Implementation of Telemedicine Integrated Ambulance-Based Environments for Stroke Car…
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digital.ahrq.gov/ahrq-funded-projects/customizing-value-based-methods-prioritize-implementation-pharmacogenomic/final-report
January 01, 2023 - Customizing Value-Based Methods to Prioritize Implementation of Pharmacogenomic Clinical Decision Support for Learning Health Systems - Final Report
Citation
Devine E. Customizing Value-Based Methods to Prioritize Implementation of Pharmacogenomic Clinical Decision Support for Learning Health Systems …
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digital.ahrq.gov/ahrq-funded-projects/clinical-decision-support-optimizing-necrotizing-enterocolitis-prevention/final-report
January 01, 2023 - Clinical Decision Support Optimizing Necrotizing Enterocolitis Prevention Implementation in Neonatal Intensive Care Unit - Final Report
Citation
Gephart SM. Clinical Decision Support Optimizing Necrotizing Enterocolitis Prevention Implementation in Neonatal Intensive Care Unit - Final Report. (Prepare…
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digital.ahrq.gov/ahrq-funded-projects/implementing-personalized-cross-sector-transitional-care-management-promote/citation/expanding
January 01, 2023 - Expanding the evidence for cross-sector collaboration in implementation science: Creating a collaborative, cross-sector, interagency, multidisciplinary team to serve patients experiencing homelessness and medical complexity at hospital discharge.
Citation
Anderson AJ, Noyes K, Hewner S. Expanding the …
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digital.ahrq.gov/ahrq-funded-projects/use-electronic-referral-system-improve-outpatient-primary-care-specialty-care/implementation-handbook
January 01, 2023 - Use of an electronic referral system to improve the outpatient primary care–specialty interface - implementation handbook.
Citation
Bell DS, Straus SG, Wu S, et al. Use of an electronic referral system to improve the outpatient primary care–specialty interface - implementation handbook. (Prepared by R…
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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - Date First Implemented
2006
Problem Addressed
Severely injured patients