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psnet.ahrq.gov/node/36163/psn-pdf
September 29, 2010 - Improving the bar-coded medication administration
system at the Department of Veterans Affairs.
September 29, 2010
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):1442-7.
https://psnet.ahrq.gov/iss…
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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/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…
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psnet.ahrq.gov/node/41497/psn-pdf
April 05, 2013 - Avoiding handover fumbles: a controlled trial of a
structured handover tool versus traditional handover
methods.
April 5, 2013
Payne CE, Stein JM, Leong T, et al. Avoiding handover fumbles: a controlled trial of a structured handover
tool versus traditional handover methods. BMJ Qual Saf. 2012;21(11):925-32. doi:1…
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psnet.ahrq.gov/node/39768/psn-pdf
August 18, 2010 - Medical team training and coaching in the veterans health
administration; assessment and impact on the first 32
facilities in the programme.
August 18, 2010
Neily J, Mills PD, Lee P, et al. Medical team training and coaching in the Veterans Health Administration;
assessment and impact on the first 32 facilities in…
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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/846449/psn-pdf
March 22, 2023 - Healthcare professionals' perception of safety culture and
the Operating Room (OR) Black Box technology before
clinical implementation: a cross-sectional survey.
March 22, 2023
Strandbygaard J, Dose N, Moeller KE, et al. Healthcare professionals’ perception of safety culture and the
Operating Room (OR) Black Box t…
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psnet.ahrq.gov/node/72670/psn-pdf
January 27, 2021 - System issues leading to "found-on-floor" incidents: a
multi-incident analysis.
January 27, 2021
Shaw J, Bastawrous M, Burns S, et al. System Issues Leading to “Found-on-Floor” Incidents: A Multi-
Incident Analysis. J Patient Saf. 2021;17(1):30-35. doi:10.1097/pts.0000000000000294.
https://psnet.ahrq.gov/issue/sys…
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psnet.ahrq.gov/node/43402/psn-pdf
October 20, 2014 - The WHO surgical safety checklist: survey of patients'
views.
October 20, 2014
Russ SJ, Rout S, Caris J, et al. The WHO surgical safety checklist: survey of patients’ views. BMJ Qual
Saf. 2014;23(11). doi:10.1136/bmjqs-2013-002772.
https://psnet.ahrq.gov/issue/who-surgical-safety-checklist-survey-patients-views
T…
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digital.ahrq.gov/funding-mechanism/developing-new-clinical-decision-support-disseminate-and-implement-evidence-based
January 01, 2023 - Developing New Clinical Decision Support to Disseminate and Implement Evidence-Based Research Findings (R18)
Scalable Decision Support and Shared Decision Making for Lung Cancer Screening
Description
Researchers successfully developed Decision Precision+, a shared decision mak…
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digital.ahrq.gov/program/general-patient-safety-program-center-quality-improvement-and-patient-safety
January 01, 2023 - General Patient Safety Program, Center for Quality Improvement and Patient Safety
Program Link: https://www.ahrq.gov/patient-safety/index.html
Artificial Intelligence and Human Factors in Healthcare Quality & Safety
Description
Using a conference model…
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digital.ahrq.gov/location/usa-ky-lexington
January 01, 2023 - USA, KY, Lexington
Disseminating and Implementing MedSMA℞T Families in Emergency Departments: A Randomized Control Trial to Assess Effectiveness of an Evidence-Based Gaming Intervention to Reduce Opioid Misuse
Description
This research tests the effectiveness of MedSMA℞T Mobil…
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digital.ahrq.gov/principal-investigator/obrien-matthew-james
January 01, 2023 - O'Brien, Matthew James
Prevent Diabetes Mellitus (PreDM) Clinical Decision Support Intervention in Community Health Centers - Final Report
Citation
O'Brien MJ. Prevent Diabetes Mellitus (PreDM) Clinical Decision Support Intervention in Community Health Centers - Final Report. …
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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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digital.ahrq.gov/events/national-web-conference-transitions-care
January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…
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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/865522/psn-pdf
April 10, 2024 - An analysis of incident reports related to electronic
medication management: how they change over time.
April 10, 2024
Kinlay M, Zheng WY, Burke R, et al. An analysis of incident reports related to electronic medication
management: how they change over time. J Patient Saf. 2024;20(3):202-208.
doi:10.1097/pts.00000…
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psnet.ahrq.gov/node/73414/psn-pdf
June 23, 2021 - Promoting the psychological well-being of healthcare
providers facing the burden of adverse events: a
systematic review of second victim support resources.
June 23, 2021
Busch IM, Moretti F, Campagna I, et al. Promoting the psychological well-being of healthcare providers
facing the burden of adverse events: a sys…
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psnet.ahrq.gov/node/42113/psn-pdf
March 20, 2013 - Preventing in-facility pressure ulcers as a patient safety
strategy: a systematic review.
March 20, 2013
Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic
review. Ann Intern Med. 2013;158(5 Pt 2):410-416. doi:10.7326/0003-4819-158-5-201303051-00008.
https:/…
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www.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
July 05, 2023 - The PRIDx framework to engage payers in reducing diagnostic errors in healthcare
Mini Review
Kisha J. Ali*, Christine A. Goeschel, Derek M. DeLia, Leah M. Blackall and Hardeep Singh
The PRIDx framework to engage payers in
reducing diagnostic errors in healthcare
https://doi.org/10.1515/dx-2023-0042
Received April 9…