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psnet.ahrq.gov/issue/changes-error-patterns-unanticipated-trauma-deaths-during-20-years-pursuit-zero-preventable
March 23, 2022 - Study
Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths.
Citation Text:
LaGrone LN, McIntyre LK, Riggle A, et al. Changes in error patterns in unanticipated trauma deaths during 20 years: In pursuit of zero preventable deaths.…
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psnet.ahrq.gov/issue/computer-assisted-process-modeling-enhance-intraoperative-safety-cardiac-surgery
July 19, 2023 - Study
Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery.
Citation Text:
Tarola CL, Quin JA, Haime ME, et al. Computer-Assisted Process Modeling to Enhance Intraoperative Safety in Cardiac Surgery. JAMA Surg. 2016;151(12):1183-1186. doi:10.1001/jamasur…
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psnet.ahrq.gov/issue/using-data-matrix-coded-sponge-counting-system-across-surgical-practice-impact-after-18
January 02, 2017 - Study
Using a data-matrix–coded sponge counting system across a surgical practice: impact after 18 months.
Citation Text:
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 S…
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psnet.ahrq.gov/issue/exploring-impact-consultants-experience-hospital-mortality-day-week-retrospective-analysis
August 04, 2015 - Study
Exploring the impact of consultants' experience on hospital mortality by day of the week: a retrospective analysis of hospital episode statistics.
Citation Text:
Ruiz M, Bottle A, Aylin PP. Exploring the impact of consultants’ experience on hospital mortality by day of the week: a …
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psnet.ahrq.gov/issue/prospective-evaluation-consultant-surgeon-sleep-deprivation-and-outcomes-more-4000
October 19, 2022 - Study
Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures.
Citation Text:
Chu MWA, Stitt LW, Fox SA, et al. Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 cons…
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psnet.ahrq.gov/issue/impact-daily-huddle-safety-perioperative-services
March 03, 2021 - Study
Impact of a daily huddle on safety in perioperative services.
Citation Text:
Tuyishime H, Claure RE, Balakrishnan K, et al. Impact of a daily huddle on safety in perioperative services. Jt Comm J Qual Patient Saf. 2024;50(9):678-683. doi:10.1016/j.jcjq.2024.04.012.
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psnet.ahrq.gov/issue/hospital-covid-19-burden-and-adverse-event-rates
June 22, 2022 - Study
Hospital COVID-19 burden and adverse event rates.
Citation Text:
Metersky ML, Rodrick D, Ho S-Y, et al. Hospital COVID-19 burden and adverse event rates. JAMA Netw Open. 2024;7(11):e2442936. doi:10.1001/jamanetworkopen.2024.42936.
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psnet.ahrq.gov/issue/missed-rationed-or-unfinished-nursing-care-scoping-review-patient-outcomes
May 29, 2024 - Review
Missed, rationed or unfinished nursing care: a scoping review of patient outcomes.
Citation Text:
Kalánková D, Kirwan M, Bartoníčková D, et al. Missed, rationed or unfinished nursing care: A scoping review of patient outcomes. J Nurs Manag. 2020;28(8):1783-1797. doi:10.1111/jonm.1…
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psnet.ahrq.gov/issue/patient-safety-orthopedic-surgery-prioritizing-key-areas-iatrogenic-harm-through-analysis
December 18, 2013 - Study
Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors.
Citation Text:
Panesar S, Carson-Stevens A, Salvilla SA, et al. Patient safety in orthopedic surgery: prioritizing ke…
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psnet.ahrq.gov/issue/simulation-study-rested-versus-sleep-deprived-anesthesiologists
September 13, 2017 - Study
Classic
Simulation study of rested versus sleep-deprived anesthesiologists.
Citation Text:
Howard SK, Gaba DM, Smith B, et al. Simulation study of rested versus sleep-deprived anesthesiologists. Anesthesiology. 2003;98(6):1345-1355. doi:10.1097/00000542-…
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psnet.ahrq.gov/issue/impact-multidisciplinary-chart-reviews-opioid-dose-reduction-and-monitoring-practices
October 11, 2023 - Study
Impact of multidisciplinary chart reviews on opioid dose reduction and monitoring practices.
Citation Text:
Rivich J, McCauliff J, Schroeder A. Impact of multidisciplinary chart reviews on opioid dose reduction and monitoring practices. Addict Behav. 2018;86:40-43. doi:10.1016/j.ad…
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psnet.ahrq.gov/issue/effect-race-and-sex-physicians-recommendations-cardiac-catheterization
July 15, 2020 - Study
The effect of race and sex on physicians' recommendations for cardiac catheterization.
Citation Text:
Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med. 2002;340(8):618-626. doi:10.1056/nejm…
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psnet.ahrq.gov/issue/patient-safety-and-problem-many-hands
June 16, 2021 - Commentary
Patient safety and the problem of many hands.
Citation Text:
Dixon-Woods M, Pronovost P. Patient safety and the problem of many hands. BMJ Qual Saf. 2016;25(7):485-488. doi:10.1136/bmjqs-2016-005232.
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psnet.ahrq.gov/issue/bias-eye-beholder-vignette-study-assess-recognition-cognitive-biases-clinical-case-workups
September 26, 2016 - Study
Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups.
Citation Text:
Zwaan L, Monteiro SD, Sherbino J, et al. Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinica…
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www.ahrq.gov/news/newsroom/case-studies/coe1304.html
April 01, 2013 - Maryland Guides Prescribers on Use of Atypical Antipsychotic Medications
Search All Impact Case Studies
April 2013
The Maryland Department of Health and Mental Hygiene used materials created by AHRQ's Effective Health Care Program to help set up a new program for appropriate use of antipsychotic medications…
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psnet.ahrq.gov/issue/creating-champions-health-care-quality-and-safety
August 04, 2021 - Study
Creating champions for health care quality and safety.
Citation Text:
Holland R, Meyers D, Hildebrand C, et al. Creating champions for health care quality and safety. Am J Med Qual. 2010;25(2):102-108. doi:10.1177/1062860609352108.
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psnet.ahrq.gov/issue/effect-us-drug-enforcement-administrations-rescheduling-hydrocodone-combination-analgesic
August 04, 2021 - Study
Effect of US Drug Enforcement Administration's rescheduling of hydrocodone combination analgesic products on opioid analgesic prescribing.
Citation Text:
Jones CM, Lurie PG, Throckmorton DC. Effect of US Drug Enforcement Administration's Rescheduling of Hydrocodone Combination Anal…
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psnet.ahrq.gov/issue/association-hospital-participation-surgical-outcomes-monitoring-program-inpatient
August 20, 2018 - Study
Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality.
Citation Text:
Etzioni DA, Wasif N, Dueck AC, et al. Association of hospital participation in a surgical outcomes monitoring program with inpatient complicati…
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psnet.ahrq.gov/issue/updating-eindhoven-clarifying-features-patient-safety-near-miss
March 13, 2024 - Study
Updating Eindhoven: clarifying the features of a patient safety near miss.
Citation Text:
Woodier N, Burnett C, Sampson P, et al. Updating Eindhoven: clarifying the features of a patient safety near miss. J Patient Saf Risk Manag. 2024;29(4):195-201. doi:10.1177/25160435241247096. …
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psnet.ahrq.gov/issue/us-national-trends-pediatric-deaths-prescription-and-illicit-opioids-1999-2016
January 23, 2017 - Study
US national trends in pediatric deaths from prescription and illicit opioids, 1999–2016.
Citation Text:
Gaither JR, Shabanova V, Leventhal JM. US National Trends in Pediatric Deaths From Prescription and Illicit Opioids, 1999-2016. JAMA Netw Open. 2018;1(8):e186558. doi:10.1001/jam…