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psnet.ahrq.gov/issue/direct-reporting-laboratory-test-results-patients-mail-enhance-patient-safety
February 15, 2011 - Study
Direct reporting of laboratory test results to patients by mail to enhance patient safety.
Citation Text:
Sung S, Forman-Hoffman VL, Wilson MC, et al. Direct reporting of laboratory test results to patients by mail to enhance patient safety. J Gen Intern Med. 2006;21(10):1075-8. …
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psnet.ahrq.gov/issue/hospital-initiated-transitional-care-interventions-patient-safety-strategy-systematic-review
August 12, 2014 - Review
Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review.
Citation Text:
Rennke S, Nguyen OK, Shoeb MH, et al. Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review. Ann Intern Med. 2013;15…
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www.ahrq.gov/es/tools/index.html?page=2
January 01, 2018 - Comprehensive Unit-based Safety Program (CUSP) The CUSP toolkit includes training tools to make care safer. More
The SHARE Approach Five-step process for clinicians and their patients More
EvidenceNOW Tools for Change Helping practices implement evidence More
Tools
The …
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psnet.ahrq.gov/issue/who-gets-benefit-doubt-performance-evaluations-medical-errors-and-production-gender
May 01, 2012 - Study
Who gets the benefit of the doubt? Performance evaluations, medical errors, and the production of gender inequality in emergency medical education.
Citation Text:
Brewer A, Osborne M, Mueller AS, et al. Who Gets the Benefit of the Doubt? Performance Evaluations, Medical Errors, an…
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psnet.ahrq.gov/issue/early-impact-2011-acgme-duty-hour-regulations-surgical-outcomes
May 01, 2015 - Study
Early impact of the 2011 ACGME duty hour regulations on surgical outcomes.
Citation Text:
Scally CP, Ryan AM, Thumma JR, et al. Early impact of the 2011 ACGME duty hour regulations on surgical outcomes. Surgery. 2015;158(6):1453-61. doi:10.1016/j.surg.2015.05.002.
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psnet.ahrq.gov/issue/40-years-behind-mask-safety-revisited
January 13, 2012 - Commentary
Classic
40 years behind the mask: safety revisited.
Citation Text:
Pierce EC. The 34th Rovenstine Lecture. 40 years behind the mask: safety revisited. Anesthesiology. 1996;84(4):965-975.
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Format:
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psnet.ahrq.gov/issue/disclosure-medical-error-parents-and-paediatric-patients-assessment-parents-attitudes-and
November 16, 2022 - Study
Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influencing factors.
Citation Text:
Matlow AG, Moody L, Laxer R, et al. Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influe…
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psnet.ahrq.gov/issue/hidden-health-it-hazards-qualitative-analysis-clinically-meaningful-documentation
January 15, 2020 - Study
Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit.
Citation Text:
Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transf…
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psnet.ahrq.gov/issue/alterations-spanish-language-interpretation-during-pediatric-critical-care-family-meetings
April 24, 2018 - Study
Alterations in Spanish language interpretation during pediatric critical care family meetings.
Citation Text:
Sinow CS, Corso I, Lorenzo J, et al. Alterations in Spanish Language Interpretation During Pediatric Critical Care Family Meetings. Crit Care Med. 2017;45(11):1915-1921. do…
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psnet.ahrq.gov/issue/team-based-intervention-reduce-impact-nonactionable-alarms-adult-intensive-care-unit
November 16, 2022 - Study
Team-based intervention to reduce the impact of nonactionable alarms in an adult intensive care unit.
Citation Text:
Yeh J, Wilson R, Young L, et al. Team-Based Intervention to Reduce the Impact of Nonactionable Alarms in an Adult Intensive Care Unit. J Nurs Care Qual. 2019;35(2):1…
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psnet.ahrq.gov/issue/role-radio-frequency-detection-system-embedded-surgical-sponges-preventing-retained-surgical
February 13, 2008 - Study
The role of radio frequency detection system embedded surgical sponges in preventing retained surgical sponges: a prospective evaluation in patients undergoing emergency surgery.
Citation Text:
Inaba K, Okoye O, Aksoy H, et al. The Role of Radio Frequency Detection System Embedded …
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psnet.ahrq.gov/issue/institution-just-culture-physician-peer-review-academic-medical-center
October 20, 2021 - Study
Institution of just culture physician peer review in an academic medical center.
Citation Text:
Volkar JK, Phrampus P, English D, et al. Institution of just culture physician peer review in an academic medical center. J Patient Saf. 2021;17(7):e689-e693. doi:10.1097/pts.00000000000…
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psnet.ahrq.gov/issue/promising-roles-pharmacists-addressing-us-opioid-crisis
May 19, 2021 - Commentary
Promising roles for pharmacists in addressing the U.S. opioid crisis.
Citation Text:
Compton WM, Jones CM, Stein JB, et al. Promising roles for pharmacists in addressing the U.S. opioid crisis. Res Social Adm Pharm. 2019;15(8):910-916. doi:10.1016/j.sapharm.2017.12.009.
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psnet.ahrq.gov/issue/managing-competing-organizational-priorities-clinical-handover-across-organizational
February 07, 2024 - Study
Managing competing organizational priorities in clinical handover across organizational boundaries.
Citation Text:
Sujan MA, Chessum P, Rudd M, et al. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2015;…
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psnet.ahrq.gov/issue/patient-safety-perspectives-providers-and-nurses-experience-rural-ambulatory-care-practice
January 13, 2010 - Study
Patient safety perspectives of providers and nurses: the experience of a rural ambulatory care practice using an EHR with e-prescribing.
Citation Text:
Bramble JD, Abbott AA, Fuji KT, et al. Patient safety perspectives of providers and nurses: the experience of a rural ambulatory …
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psnet.ahrq.gov/issue/frailty-and-potentially-inappropriate-prescribing-older-people-polypharmacy-bi-directional
November 16, 2022 - Review
Frailty and potentially inappropriate prescribing in older people with polypharmacy: a bi-directional relationship?
Citation Text:
Randles MA. Frailty and potentially inappropriate prescribing in older people with polypharmacy: a bi-directional relationship? Drugs Aging. 2022;39(8…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cap-toolkit/pc-workflowdiagrams.pdf
January 01, 2018 - Primary Care Workflow Diagrams
Primary Care
Workflow Diagrams
Patient arrives.
Patient in the EHR?
Patient completes
paperwork.
Front desk flags patient
in EHR as ready for
room.
MA available?
Waiting room.
MA takes temp, RR,
oxgen saturation, and
BP.
MA flags patient in EHR
as ready to be seen.
Pro…
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psnet.ahrq.gov/issue/improving-resident-physician-participation-reporting-patient-safety-and-quality-concerns
May 18, 2022 - Study
Improving resident physician participation in reporting patient safety and quality concerns.
Citation Text:
Craig SR, Smith HL, Shaeffer PJ. Improving resident physician participation in reporting patient safety and quality concerns. Ochsner J. 2024;24(2):118-123. doi:10.31486/toj.…
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psnet.ahrq.gov/issue/personal-health-records-randomized-trial-effects-elder-medication-safety
November 16, 2022 - Study
Personal health records: a randomized trial of effects on elder medication safety.
Citation Text:
Chrischilles EA, Hourcade JP, Doucette W, et al. Personal health records: a randomized trial of effects on elder medication safety. J Am Med Inform Assoc. 2014;21(4):679-86. doi:10.113…
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psnet.ahrq.gov/issue/association-measured-quality-and-future-financial-performance-among-hospitals-performing
May 04, 2022 - Study
Association of measured quality and future financial performance among hospitals performing cardiac surgery.
Citation Text:
Enumah SJ, Sundt TM, Chang DC. Association of measured quality and future financial performance among hospitals performing cardiac surgery. J Healthc Manag. 2…