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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
June 01, 2014 - PowerPoint Presentation
Spotlight
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
1
This presentation is based on the June 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Thomas A. Smith, CHPA, CPP, President, Healthc…
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psnet.ahrq.gov/node/43579/psn-pdf
October 08, 2014 - Implications of Health Literacy for Public Health:
Workshop Summary.
October 8, 2014
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health
Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/60842/psn-pdf
August 26, 2020 - Longitudinal medication reconciliation at hospital
admission, discharge and post-discharge.
August 26, 2020
Daliri S, Bouhnouf M, van de Meerendonk HWPC, et al. Longitudinal medication reconciliation at hospital
admission, discharge and post-discharge. Res Social Adm Pharm. 2020;17(4):677-684.
doi:10.1016/j.saphar…
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psnet.ahrq.gov/node/40672/psn-pdf
September 03, 2011 - Didactic and simulation nontechnical skills team training
to improve perinatal patient outcomes in a community
hospital.
September 3, 2011
Riley W, Davis SE, Miller KK, et al. Didactic and simulation nontechnical skills team training to improve
perinatal patient outcomes in a community hospital. Jt Comm J Qual Pat…
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psnet.ahrq.gov/node/34982/psn-pdf
July 14, 2010 - Development of the ICU safety reporting system.
July 14, 2010
Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1(1):23-32.
https://psnet.ahrq.gov/issue/development-icu-safety-reporting-system
This AHRQ-funded study describes the development of a Web-based, voluntary, and anonymous reporting
system. T…
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psnet.ahrq.gov/node/46866/psn-pdf
May 23, 2018 - Improving maternal safety at scale with the mentor model
of collaborative improvement.
May 23, 2018
Main EK, Dhurjati R, Cape V, et al. Improving Maternal Safety at Scale with the Mentor Model of
Collaborative Improvement. Jt Comm J Qual Patient Saf. 2018;44(5):250-259.
doi:10.1016/j.jcjq.2017.11.005.
https://psn…
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psnet.ahrq.gov/node/34715/psn-pdf
February 18, 2011 - Continuous improvement as an ideal in health care.
February 18, 2011
Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56.
https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care
Two approaches to improving quality in health care are illustrated in this artic…
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psnet.ahrq.gov/node/47601/psn-pdf
December 21, 2018 - Clinical decision support in the era of artificial
intelligence.
December 21, 2018
Shortliffe EH, Sepúlveda MJ. Clinical Decision Support in the Era of Artificial Intelligence. JAMA.
2018;320(21):2199-2200. doi:10.1001/jama.2018.17163.
https://psnet.ahrq.gov/issue/clinical-decision-support-era-artificial-intellige…
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psnet.ahrq.gov/node/867700/psn-pdf
March 01, 2023 - Toolkit for Reducing Central Line-Associated Blood
Stream Infections.
March 1, 2023
Agency for Healthcare Research and Quality. Toolkit for Reducing Central Line-Associated Blood Stream
Infections. March 2023.
https://psnet.ahrq.gov/issue/toolkit-reducing-central-line-associated-blood-stream-infections
Eliminatin…
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psnet.ahrq.gov/node/848383/psn-pdf
May 03, 2023 - Burnout in Primary Care: Assessing and Addressing It in
Your Practice.
May 3, 2023
Gerteis J, Booker C, Brach C, et al. Rockville, MD: Agency for Healthcare Research and Quality;
February 2023. AHRQ Publication No. 23-0025.
https://psnet.ahrq.gov/issue/burnout-primary-care-assessing-and-addressing-it-your-pr…
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psnet.ahrq.gov/node/46901/psn-pdf
May 30, 2018 - Physician resiliency and wellness for transforming a
health system.
May 30, 2018
Armato CS, Jenike TE. NEJM Catalyst. May 2, 2018.
https://psnet.ahrq.gov/issue/physician-resiliency-and-wellness-transforming-health-system
Physician burnout can contribute to medical errors. This article discusses an organizational e…
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psnet.ahrq.gov/node/45234/psn-pdf
November 18, 2016 - Recommended responsibilities for management of MR
safety.
November 18, 2016
Calamante F, Ittermann B, Kanal E, et al. Recommended responsibilities for management of MR safety. J
Magn Reson Imaging. 2016;44(5):1067-1069. doi:10.1002/jmri.25282.
https://psnet.ahrq.gov/issue/recommended-responsibilities-management-mr…
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psnet.ahrq.gov/node/863757/psn-pdf
March 06, 2024 - Debriefing to improve interprofessional teamwork in the
operating room: a systematic review.
March 6, 2024
Skegg E, McElroy C, Mudgway M, et al. Debriefing to improve interprofessional teamwork in the operating
room: a systematic review. J Nurs Scholarsh. 2023;55(6):1179-1188. doi:10.1111/jnu.12924.
https://psnet.…
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psnet.ahrq.gov/node/42116/psn-pdf
March 20, 2013 - Rapid response systems as a patient safety strategy: a
systematic review.
March 20, 2013
Winters BD, Weaver SJ, Pfoh ER, et al. Rapid-response systems as a patient safety strategy: a systematic
review. Ann Intern Med. 2013;158(5 Pt 2):417-25. doi:10.7326/0003-4819-158-5-201303051-00009.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/48133/psn-pdf
November 01, 2024 - The NHS Patient Safety Strategy.
November 1, 2024
NHS England
https://psnet.ahrq.gov/issue/nhs-patient-safety-strategy
The United Kingdom National Health Service (NHS) has been at the forefront of patient safety innovation.
This strategy seeks to further implement approaches that explore and optimize the intersect…
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psnet.ahrq.gov/node/43129/psn-pdf
July 23, 2014 - Use of a daily goals checklist for morning ICU rounds: a
mixed-methods study.
July 23, 2014
Centofanti JE, Duan EH, Hoad NC, et al. Use of a daily goals checklist for morning ICU rounds: a mixed-
methods study. Crit Care Med. 2014;42(8):1797-803. doi:10.1097/CCM.0000000000000331.
https://psnet.ahrq.gov/issue/use-d…
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psnet.ahrq.gov/node/40182/psn-pdf
September 25, 2011 - Using a data-matrix–coded sponge counting system
across a surgical practice: impact after 18 months.
September 25, 2011
Cima RR, Kollengode A, Clark J, et al. Using a data-matrix-coded sponge counting system across a
surgical practice: impact after 18 months. Jt Comm J Qual Patient Saf. 2011;37(2):51-58.
https://p…
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psnet.ahrq.gov/node/850911/psn-pdf
June 21, 2023 - International perspectives on modifications to the
surgical safety checklist.
June 21, 2023
Turley N, Elam M, Brindle ME. International perspectives on modifications to the surgical safety checklist.
JAMA Netw Open. 2023;6(6):e2317183. doi:10.1001/jamanetworkopen.2023.17183.
https://psnet.ahrq.gov/issue/internatio…
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psnet.ahrq.gov/node/44940/psn-pdf
September 20, 2016 - Dual-process cognitive interventions to enhance
diagnostic reasoning: a systematic review.
September 20, 2016
Lambe KA, O'Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic
reasoning: a systematic review. BMJ Qual Saf. 2016;25(10):808-820. doi:10.1136/bmjqs-2015-004417.
https://p…
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psnet.ahrq.gov/node/34797/psn-pdf
October 06, 2015 - Adapting to new technologies in the operating room.
October 6, 2015
Cook RI, Woods DD. Adapting to New Technology in the Operating Room. Hum Factors. 2006;38(4):593-
613. doi:10.1518/001872096778827224.
https://psnet.ahrq.gov/issue/adapting-new-technologies-operating-room
New technology continues to offer great ad…