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  1. Factors influencing patient safety during postoperative handover. | PSNet

    psnet.ahrq.gov/issue/factors-influencing-patient-safety-during-postoperative-handover
    March 03, 2021 - Review Factors influencing patient safety during postoperative handover. Citation Text: Factors influencing patient safety during postoperative handover. Rose M, Newman SD. AANA J. 2016;84:329-338. Copy Citation Save Save to your library Print Download P…

  2. Effective approaches to control non-actionable alarms and alarm fatigue. | PSNet

    psnet.ahrq.gov/issue/effective-approaches-control-non-actionable-alarms-and-alarm-fatigue
    January 15, 2025 - Commentary Effective approaches to control non-actionable alarms and alarm fatigue. Citation Text: Winters BD. Effective approaches to control non-actionable alarms and alarm fatigue. J Electrocardiol. 2018;51(6S):S49-S51. doi:10.1016/j.jelectrocard.2018.07.007. Copy Citation Forma…

  3. Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. | PSNet

    psnet.ahrq.gov/issue/tapping-front-line-knowledge-identifying-problems-they-occur-helps-enhance-patient-safety
    July 21, 2009 - Newspaper/Magazine Article Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. Citation Text: Luther K, Resar RK. Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. Healthcare executive. 2013;28(1):84-…

  4. Patient safety: planting the seed. | PSNet

    psnet.ahrq.gov/issue/patient-safety-planting-seed
    February 09, 2011 - Commentary Patient safety: planting the seed. Citation Text: Poe SS. Patient safety: planting the seed. J Nurs Care Qual. 2005;20(3):198-202. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cit…

  5. The meaning of justice in safety incident reporting. | PSNet

    psnet.ahrq.gov/issue/meaning-justice-safety-incident-reporting
    April 11, 2011 - Commentary The meaning of justice in safety incident reporting. Citation Text: Weiner BJ, Hobgood C, Lewis MA. The meaning of justice in safety incident reporting. Soc Sci Med. 2008;66(2):403-13. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 …

  6. Using Federal grants to build intellectual capital at the State level | Agency for Healthcare Research and Quality

    www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/finalsummary/finalsummary7.html
    September 01, 2015 - Key Lessons from the National Evaluation of the CHIPRA Quality Demonstration Grant Program Using Federal grants to build intellectual capital at the State level Previous Page Next Page Table of Contents Key Lessons from the National Evaluation of the CHIPRA Quality Demonstration Grant Program Intr…

  7. Patient safety rounds: description of an inexpensive but important strategy to improve the safety culture. | PSNet

    psnet.ahrq.gov/issue/patient-safety-rounds-description-inexpensive-important-strategy-improve-safety-culture
    December 15, 2008 - Commentary Patient safety rounds: description of an inexpensive but important strategy to improve the safety culture. Citation Text: Campbell D, Thompson M. Patient safety rounds: description of an inexpensive but important strategy to improve the safety culture. Am J Med Qual. 2007;22…

  8. The cost of serious fall-related injuries at three midwestern hospitals. | PSNet

    psnet.ahrq.gov/issue/cost-serious-fall-related-injuries-three-midwestern-hospitals
    January 03, 2017 - Study The cost of serious fall-related injuries at three midwestern hospitals. Citation Text: Wong CA, Recktenwald AJ, Jones ML, et al. The cost of serious fall-related injuries at three Midwestern hospitals. Jt Comm J Qual Patient Saf. 2011;37(2):81-87. Copy Citation Format: …

  9. Patient safety during anaesthesia: incorporation of the WHO safe surgery guidelines into clinical practice. | PSNet

    psnet.ahrq.gov/issue/patient-safety-during-anaesthesia-incorporation-who-safe-surgery-guidelines-clinical-practice
    September 20, 2011 - Review Patient safety during anaesthesia: incorporation of the WHO safe surgery guidelines into clinical practice. Citation Text: Schlack WS, Boermeester MA. Patient safety during anaesthesia: incorporation of the WHO safe surgery guidelines into clinical practice. Curr Opin Anaesthesi…

  10. Edgeware: Insights from Complexity Science for Health Care Leaders. Second ed. | PSNet

    psnet.ahrq.gov/issue/edgeware-insights-complexity-science-health-care-leaders
    June 23, 2021 - Book/Report Edgeware: Insights from Complexity Science for Health Care Leaders. Second ed. Citation Text: Edgeware: Insights from Complexity Science for Health Care Leaders. Second ed. Zimmerman B, Lindberg C, Plsek P. Irving, TX: VHA Incorporated; 2008. ISBN: 9780966782806 Copy Citati…

  11. Avoiding medical emergencies. | PSNet

    psnet.ahrq.gov/issue/avoiding-medical-emergencies
    April 07, 2021 - Commentary Avoiding medical emergencies. Citation Text: Omar Y. Avoiding medical emergencies. Br Dent J. 2013;214(5):255-9. doi:10.1038/sj.bdj.2013.217. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  12. Exhibit 5.4. Chronology of Quality Improvement (QI) and Lean at Heights Hospital | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-4.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 5.4. Chronology of Quality Improvement (QI) and Lean at Heights Hospital Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. …

  13. Clinical decision support and malpractice risk. | PSNet

    psnet.ahrq.gov/issue/clinical-decision-support-and-malpractice-risk
    September 24, 2017 - Commentary Clinical decision support and malpractice risk. Citation Text: Greenberg MD, Ridgely MS. Clinical Decision Support and Malpractice Risk. JAMA. 2011;306(1). doi:10.1001/jama.2011.929. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…

  14. Alcohol based surgical prep solution and the risk of fire in the operating room: a case report. | PSNet

    psnet.ahrq.gov/issue/alcohol-based-surgical-prep-solution-and-risk-fire-operating-room-case-report
    February 02, 2022 - Commentary Alcohol based surgical prep solution and the risk of fire in the operating room: a case report. Citation Text: Batra S, Gupta R. Alcohol based surgical prep solution and the risk of fire in the operating room: a case report. Patient Saf Surg. 2008;2(1):10. doi:10.1186/1754-9…

  15. Rapid response systems: should we still question their implementation? | PSNet

    psnet.ahrq.gov/issue/rapid-response-systems-should-we-still-question-their-implementation
    January 06, 2017 - Commentary Rapid response systems: should we still question their implementation? Citation Text: Winters BD, Pronovost P. Rapid response systems: should we still question their implementation? J Hosp Med. 2013;8(5):278-81. doi:10.1002/jhm.2050. Copy Citation Format: DOI G…

  16. Rapid response teams: what's the latest? | PSNet

    psnet.ahrq.gov/issue/rapid-response-teams-whats-latest
    December 12, 2012 - Commentary Rapid response teams: what's the latest? Citation Text: Jackson SA. Rapid response teams: What's the latest? Nursing (Brux). 2017;47(12):34-41. doi:10.1097/01.NURSE.0000526885.10306.21. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote…

  17. Hypertension Screening for Children Who Are Overweight or Obese: Technical Specifications (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-technicalspecs.pdf
    June 02, 2025 - Hypertension Screening for Children Who Are Overweight or Obese: Technical Specifications The percentage of children aged 3 through 17 years with an outpatient care visit and a BMI ≥85th percentile who had a blood pressure percentile documented and classified as normal or abnormal during the measure…

  18. Rethinking peer review: what aviation can teach radiology about performance improvement. | PSNet

    psnet.ahrq.gov/issue/rethinking-peer-review-what-aviation-can-teach-radiology-about-performance-improvement
    July 01, 2017 - Commentary Rethinking peer review: what aviation can teach radiology about performance improvement. Citation Text: Larson DB, Nance JJ. Rethinking peer review: what aviation can teach radiology about performance improvement. Radiology. 2011;259(3):626-32. doi:10.1148/radiol.11102222. …

  19. The spectrum of medical errors: when patients sue. | PSNet

    psnet.ahrq.gov/issue/spectrum-medical-errors-when-patients-sue
    October 28, 2020 - Review The spectrum of medical errors: when patients sue. Citation Text: Grant-Kels J, Kels B. The spectrum of medical errors: when patients sue. Int J Gen Med. 2012. doi:10.2147/ijgm.s24257. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

  20. CDS Connect Implementation Guide Draft (doc file)

    cds.ahrq.gov/sites/default/files/cds/artifact/18/Implementation%20Guide_USPSTF%20Statin%20Use%20for%20the%20Primary%20Prevention%20of%20CVD%20in%20Adults_Final.docx
    October 01, 2017 - Verify completeness Diagnosis of Active Pregnancy as an Exclusion Statins are not indicated for pregnant … Verify completeness Pregnancy Observation as an Exclusion Statins are not indicated for pregnant women … Verify completeness Diagnosis: Breastfeeding added as an Exclusion Statins are not indicated for women … Verify completeness Actively undergoing dialysis added as an Exclusion Statins are not indicated for … Verify completeness Diagnosis of Active Cirrhosis added as an Exclusion Statins are not indicated for
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