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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - July 5, 2017
Implementing a distraction-free practice with the Red Zone Medication Safety
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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - distractors, convoluted processes, and system misconfiguration. 2 Despite error reduction efforts through implementing
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - Health systems have made attempts to decrease the likelihood of adverse drug events by implementing health
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - WebM&M Cases
Crossing the Line
March 1, 2004
Implementing
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psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
August 15, 2017 - Implementing evidence-based protocols in the evaluation of the acute ischemic stroke patient, ensuring
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psnet.ahrq.gov/web-mm/result-stopped-here
December 01, 2006 - Medicare, Medicaid and CLIA programs; regulations implementing the Clinical Laboratory Improvement Amendments
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - Implementing ways to increase feedback will enhance quality and may minimize error.( 14 ) Especially
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psnet.ahrq.gov/node/37024/psn-pdf
January 02, 2017 - Every error a treasure: improving medication use with a
nonpunitive reporting system.
January 2, 2017
Lehmann DF, Page N, Kirschman K, et al. Every Error a Treasure: Improving Medication Use with a
Nonpunitive Reporting System. Jt Comm J Qual Patient Saf. 2016;33(7):401-407. doi:10.1016/s1553-
7250(07)33046-8.
ht…
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psnet.ahrq.gov/node/47262/psn-pdf
August 22, 2018 - The Case for Medication Safety Officers (MSO).
August 22, 2018
Horsham, PA: Institute for Safe Medication Practices; 2018.
https://psnet.ahrq.gov/issue/case-medication-safety-officers-mso
Medication safety is a concern in various settings across an organization. This white paper discusses the
role of a medication …
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psnet.ahrq.gov/node/38446/psn-pdf
May 07, 2014 - Inpatient Computerized Provider Order Entry: Findings
from the AHRQ Health IT Portfolio.
May 7, 2014
Dixon BE, Zafar A, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for
Healthcare Research and Quality; January 2009. AHRQ Publication No. 09-0031-EF.
https://psnet.ahrq.gov/issue/inpatient-c…
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psnet.ahrq.gov/node/36065/psn-pdf
May 27, 2011 - Passing the "Yo' Mama" test.
May 27, 2011
Blair R. Passing the "Yo' Mama" test. Atlanta healthcare organization follows the beat of a different
drummer in achieving 100 percent CPOE adoption. Health Manag Technol. 2006;27(6):14, 16, 18.
https://psnet.ahrq.gov/issue/passing-yo-mama-test
This article discusses how a…
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psnet.ahrq.gov/node/42512/psn-pdf
August 21, 2013 - Project BOOST: effectiveness of a multihospital effort to
reduce rehospitalization.
August 21, 2013
Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: effectiveness of a multihospital effort to
reduce rehospitalization. J Hosp Med. 2013;8(8):421-7. doi:10.1002/jhm.2054.
https://psnet.ahrq.gov/issue/project-…
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psnet.ahrq.gov/node/35441/psn-pdf
September 18, 2009 - Bridging the communication gap in the operating room
with medical team training.
September 18, 2009
Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical
team training. Am J Surg. 2005;190(5):770-4.
https://psnet.ahrq.gov/issue/bridging-communication-gap-operating-r…
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psnet.ahrq.gov/node/39778/psn-pdf
August 18, 2010 - Eight-year experience with a neurosurgical checklist.
August 18, 2010
Lyons MK. Eight-year experience with a neurosurgical checklist. Am J Med Qual. 2010;25(4):285-8.
doi:10.1177/1062860610363305.
https://psnet.ahrq.gov/issue/eight-year-experience-neurosurgical-checklist
A 6-item checklist was successfully impleme…
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psnet.ahrq.gov/node/38908/psn-pdf
January 03, 2017 - Rapid response systems in adult academic medical
centers.
January 3, 2017
Wood KA, Ranji SR, Ide B, et al. Rapid response systems in adult academic medical centers. Jt Comm J
Qual Patient Saf. 2009;35(9):475-82, 437.
https://psnet.ahrq.gov/issue/rapid-response-systems-adult-academic-medical-centers
This survey ch…
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psnet.ahrq.gov/node/46500/psn-pdf
June 27, 2018 - Ariadne Labs.
June 27, 2018
Brigham & Women's Hospital; Harvard T.H. Chan School of Public Health.
https://psnet.ahrq.gov/issue/ariadne-labs
Checklists can help catch gaps in communication and process. This website provides resources related to
the use of checklists in surgical, obstetric, and other care environme…
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psnet.ahrq.gov/node/38264/psn-pdf
January 02, 2017 - Using an advanced practice nursing model for a rapid
response team.
January 2, 2017
Benson L, Mitchell C, Link M, et al. Using an advanced practice nursing model for a rapid response team.
Jt Comm J Qual Patient Saf. 2008;34(12):743-7.
https://psnet.ahrq.gov/issue/using-advanced-practice-nursing-model-rapid-respon…
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psnet.ahrq.gov/node/50665/psn-pdf
November 13, 2019 - The SECOND Trial
November 13, 2019
Northwestern University Feinberg School of Medicine
https://psnet.ahrq.gov/issue/second-trial
Surgical resident well-being is paramount to ensuring safe surgical care and a healthy workforce. This
website shares information on the Surgical Education Culture Optimization through t…
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psnet.ahrq.gov/node/47352/psn-pdf
February 13, 2019 - When is the surgeon too old to operate?
February 13, 2019
Span P. New York Times. February 1, 2019.
https://psnet.ahrq.gov/issue/when-surgeon-too-old-operate
Cognitive and functional decline can occur as individuals age. Concerns have been raised regarding the
need to assess skills of aging physicians. This newspa…
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psnet.ahrq.gov/node/41836/psn-pdf
November 14, 2012 - "Team time-out" and surgical safety—experiences in
12,390 neurosurgical patients.
November 14, 2012
Oszvald Á, Vatter H, Byhahn C, et al. “Team time-out” and surgical safety—experiences in 12,390
neurosurgical patients. Neurosurg Focus. 2012;33(5). doi:10.3171/2012.8.focus12261.
https://psnet.ahrq.gov/issue/team-t…