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psnet.ahrq.gov/node/36338/psn-pdf
October 26, 2010 - Who is in charge of patient safety? Work practice, work
processes and utopian views of automatic drug
dispensing systems.
October 26, 2010
Balka E, Kahnamoui N, Nutland K. Who is in charge of patient safety? Work practice, work processes and
utopian views of automatic drug dispensing systems. Int J Med Inform. 200…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-3.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 6.3. Characteristics of Lakeview Healthcare (All Hospitals)
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Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Heal…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-1.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 3.1. Interviewees by Type of Participant and Clinical Role
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healt…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-11.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 5.11. Project Organizational Structure and Roles
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Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Ca…
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psnet.ahrq.gov/node/45682/psn-pdf
November 01, 2017 - Changing smart pump vendors: lessons learned.
November 1, 2017
Arthur KJ, Catlin AC, Quebe A, et al. Changing Smart Pump Vendors: Lessons Learned. Hosp Pharm.
2016;51(9):782-789.
https://psnet.ahrq.gov/issue/changing-smart-pump-vendors-lessons-learned
Changes in processes, devices, and technologies can increase ri…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-1.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 5.1. Safety Net System Interviewees by Type of Participant and Clinical Role
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Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case…
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psnet.ahrq.gov/node/854252/psn-pdf
October 04, 2023 - Standardization and visualization of the surgical time-out.
October 4, 2023
Levy BE, Wilt WS, Lantz S, et al. Standardization and visualization of the surgical time-out. J Patient Saf.
2023;19(7):453-459. doi:10.1097/pts.0000000000001156.
https://psnet.ahrq.gov/issue/standardization-and-visualization-surgical-time-…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-11.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 6.11. Lean Tools for Horizon Hospital
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Case 2. Centr…
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psnet.ahrq.gov/node/46736/psn-pdf
December 17, 2018 - Back to basics: the Universal Protocol.
December 17, 2018
Spruce L. Back to Basics: The Universal Protocol: 1.4 www.aornjournal.org/content/cme. AORN J.
2018;107(1):116-125. doi:10.1002/aorn.12002.
https://psnet.ahrq.gov/issue/back-basics-universal-protocol
Wrong-site, wrong-procedure, and wrong-patient errors are…
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psnet.ahrq.gov/node/47695/psn-pdf
June 14, 2019 - No shortcuts to safer opioid prescribing.
June 14, 2019
Dowell D, Haegerich T, Chou R. No Shortcuts to Safer Opioid Prescribing. N Engl J Med.
2019;380(24):2285-2287. doi:10.1056/NEJMp1904190.
https://psnet.ahrq.gov/issue/no-shortcuts-safer-opioid-prescribing
Improving opioid prescribing is a complex challenge tha…
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digital.ahrq.gov/ahrq-funded-projects/patient-centered-outcomes-research-clinical-decision-support-current-state-and/citation/implementation
January 01, 2023 - Implementation and evaluation of an electronic health record-integrated app for postpartum monitoring of hypertensive disorders of pregnancy using patient-contributed data collection.
Citation
Dullabh P, Heaney-Huls KK, Chiao AB, Callaham MG, Desai P, Gauthreaux NA, Kashyap N, Lobach DF, Boxwala A. Im…
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psnet.ahrq.gov/node/854634/psn-pdf
January 01, 2024 - Elopement: evidence-based mitigation and management.
October 18, 2023
Marlett JE, Vacovsky BA, Krug EA, et al. Elopement: evidence?based mitigation and management.
Worldviews Evid Based Nurs. 2024;20(6):634-641. doi:10.1111/wvn.12683.
https://psnet.ahrq.gov/issue/elopement-evidence-based-mitigation-and-management
…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit7.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 7. Interviews by Position in Organization
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Case 2. C…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit1-1.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 1.1. Interviewees by Type of Participant and Clinical Role (As of September 1, 2011)
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studie…
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digital.ahrq.gov/ahrq-funded-projects/using-mhealth-and-patient-reported-outcomes-deliver-evidence-based-asthma-care/citation/clinically
January 01, 2023 - A clinically integrated mHealth app and practice model for collecting patient-reported outcomes between visits for asthma patients: implementation and feasibility.
Citation
Rudin RS, Fanta CH, Qureshi N, Duffy E, Edelen MO, Dalal AK, Bates DW. A clinically integrated mHealth app and practice model for…
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digital.ahrq.gov/ahrq-funded-projects/health-information-technology-nursing-home/citation/costs-associated-developing
January 01, 2023 - Costs associated with developing and implementing a computerized clinical decision support system for medication dosing for patients with renal insufficiency in the long-term care setting.
Citation
Field TS, Rochon P, Lee M, et al. Costs associated with developing and implementing a computerized clini…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care
Monitoring for Perinatal Safety: Electronic Fetal Monitoring
Monitoring for Perinatal Safety—Electronic Fetal Monitoring
SAY:
The Monitoring for Perinatal Safety bundle provides information on the use of electronic fetal monitoring (EFM). This bundle offers an approach to the us…
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integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/collect-and-use-data-quality-improvement
August 01, 2025 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
Contact Us
Español
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Email Updates
The Academy
Integrating Behavioral Health & Primary Care
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/102-how-to-integrate-cusp-approach-periop.pptx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
AHRQ Safety Program for MRSA Prevention: Targeting SSI
How To Integrate a Comprehensive Unit-based Safety Program
(CUSP) Approach
in the Perioperative Setting
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
AHRQ Pub. …
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www.ahrq.gov/sites/default/files/publications2/files/dx-safety-21-diagnostic-stewardship.pdf
August 01, 2024 - After the hospital implemented a combination of
interventions, including emails to clinicians and modifications … process changes that can help program leaders assess whether new policies
and practices are being implemented