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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40289/psn-pdf
    March 16, 2011 - Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers. March 16, 2011 Spiller HA, Borys DJ, Ryan ML, et al. Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers. Ann Pharmacother. 2011;45(1):17-22. doi:10.1345/aph.1…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47991/psn-pdf
    July 12, 2019 - What quality and safety of care for patients admitted to clinically inappropriate wards: a systematic review. July 12, 2019 La Regina M, Guarneri F, Romano E, et al. What Quality and Safety of Care for Patients Admitted to Clinically Inappropriate Wards: a Systematic Review. J Gen Intern Med. 2019;34(7):1314-1321. …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46806/psn-pdf
    January 01, 2020 - Examining the relationship of an all-cause harm patient safety measure and critical performance measures at the frontline of care. February 28, 2018 Sammer C, Hauck L, Jones C, et al. Examining the Relationship of an All-Cause Harm Patient Safety Measure and Critical Performance Measures at the Frontline of Care. …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45419/psn-pdf
    June 29, 2017 - Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study. June 29, 2017 Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study.…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42924/psn-pdf
    April 24, 2014 - Role-modeling and medical error disclosure: a national survey of trainees. April 24, 2014 Martinez W, Hickson GB, Miller BM, et al. Role-modeling and medical error disclosure: a national survey of trainees. Acad Med. 2014;89(3):482-9. doi:10.1097/ACM.0000000000000156. https://psnet.ahrq.gov/issue/role-modeling-and…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40565/psn-pdf
    June 29, 2011 - National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. June 29, 2011 Pham JC, Story JL, Hicks RW, et al. National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. J Emerg…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47666/psn-pdf
    January 01, 2020 - A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study. February 6, 2019 Lane-Fall MB, Pascual JL, Peifer HG, et al. A Partially Structured Postoperative Ha…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39215/psn-pdf
    January 03, 2017 - Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance. January 3, 2017 Classen D, Jaser L, Budnitz DS. Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance. Jt Co…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45352/psn-pdf
    September 01, 2018 - Predictors of gaps in patient safety and quality in U.S. hospitals. September 1, 2018 Unruh L, Hofler R. Predictors of Gaps in Patient Safety and Quality in U.S. Hospitals. Health Serv Res. 2016;51(6):2258-2281. doi:10.1111/1475-6773.12468. https://psnet.ahrq.gov/issue/predictors-gaps-patient-safety-and-quality-us…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40601/psn-pdf
    September 29, 2017 - A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative. September 29, 2017 Arriaga AF, Elbardissi AW, Regenbogen SE, et al. A policy-based intervention for the reduction of communication breakdowns in inpatient surg…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42423/psn-pdf
    July 17, 2013 - National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA. July 17, 2013 Sukumar S, Roghmann F, Trinh VQ, et al. National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA. BMJ Open. 2013;3(6). doi:10.1136/bmjopen-2013-002843. h…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46299/psn-pdf
    September 13, 2017 - Simulation-based assessment of the management of critical events by board-certified anesthesiologists. September 13, 2017 Weinger MB, Banerjee A, Burden AR, et al. Simulation-based assessment of the management of critical events by board-certified anesthesiologists. Anesthesiology. 2017;127(3):475-489. doi:10.1097…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46662/psn-pdf
    August 20, 2018 - Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study. August 20, 2018 Aldridge C, Bion J, Boyal A, et al. Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study. Lancet. 2016;388(10040):178-86. do…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47261/psn-pdf
    August 15, 2018 - The association between professional burnout and engagement with patient safety culture and outcomes: a systematic review. August 15, 2018 Mossburg SE, Himmelfarb CD. The Association Between Professional Burnout and Engagement With Patient Safety Culture and Outcomes: A Systematic Review. J Patient Saf. 2018;17(8)…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45310/psn-pdf
    January 03, 2017 - Minding the gaps: assessing communication outcomes of electronic preconsultation exchange. January 3, 2017 Price EL, Sewell JL, Chen AH, et al. Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange. Jt Comm J Qual Patient Saf. 2016;42(8):341-54. https://psnet.ahrq.gov/issue/mind…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40995/psn-pdf
    January 04, 2012 - Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. January 4, 2012 van Klei WA, Hoff RG, van Aarnhem EEHL, et al. Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. Ann Surg. 2012;255(1):44-9. doi:10…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38710/psn-pdf
    September 14, 2009 - Patient readmissions, emergency visits, and adverse events after software-assisted discharge from hospital: cluster randomized trial. September 14, 2009 Graumlich JF, Novotny NL, Nace S, et al. Patient readmissions, emergency visits, and adverse events after software-assisted discharge from hospital: cluster rando…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43419/psn-pdf
    October 20, 2014 - Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center. October 20, 2014 McKaig D, Collins C, Elsaid KA. Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements …

  19. Material Use Guide - Implementation Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-k-material-guide.html
    May 01, 2017 - Material Use Guide - Implementation Guide Overview of Quality Improvement Study Components A systematic approach to quality improvement work greatly increases the odds of achieving the desired outcomes of a given project. Adherence to a standardized framework ensures that all essential elements of a project a…

  20. Written Statement (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-177-written-statement.pdf
    June 02, 2025 - Written Statement ISection XIV: Additional Information Complete information about the person submitting the material, including: Principal Investigator Sarah Hudson Scholle, MPH, DrPH Vice President, Research and Analysis National Committee for Quality Assurance {NCQA) 110013th St, NW, Ste. 1000; Washington,…
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