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8901. Analysis of adverse events associated with adult moderate procedural sedation outside the operating room. | PSNet
      psnet.ahrq.gov/issue/analysis-adverse-events-associated-adult-moderate-procedural-sedation-outside-operating-room
      August 13, 2014 - Study Analysis of adverse events associated with adult moderate procedural sedation outside the operating room. Citation Text: Karamnov S, Sarkisian N, Grammer R, et al. Analysis of Adverse Events Associated With Adult Moderate Procedural Sedation Outside the Operating Room. J Patient Sa…

8902. Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017. | PSNet
      psnet.ahrq.gov/issue/registration-errors-among-patients-receiving-blood-transfusions-national-analysis-2008-2017
      March 18, 2020 - Study Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017. Citation Text: Vijenthira S, Armali C, Downie H, et al. Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017. Vox Sang. 2021;116…

8903. Impact of errors in paper-based and computerized diabetes management with decision support for hospitalized patients with type 2 diabetes. A post-hoc analysis of a before and after study. | PSNet
      psnet.ahrq.gov/issue/impact-errors-paper-based-and-computerized-diabetes-management-decision-support-hospitalized
      April 03, 2024 - Study Impact of errors in paper-based and computerized diabetes management with decision support for hospitalized patients with type 2 diabetes. A post-hoc analysis of a before and after study. Citation Text: Donsa K, Beck P, Höll B, et al. Impact of errors in paper-based and computerize…

8904. Job Aid: Practice Assessments and Surveys (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-practice-assessments.pdf
      June 02, 2025 - Job Aid: Practice Assessments and Surveys Primary Care Practice Facilitator Training Series 1 Job Aid: Practice Assessments and Surveys Overview Practice assessments and surveys are simple and non-threatening ways for a practice to gather information, generate ideas for improvements, and test and…

8905. Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery. | PSNet
      psnet.ahrq.gov/issue/reducing-burden-surgical-harm-systematic-review-interventions-used-reduce-adverse-events
      June 21, 2016 - Review Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery. Citation Text: Howell A-M, Panesar S, Burns EM, et al. Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse eve…

8906. A report of information technology and health deficiencies in U.S. nursing homes. | PSNet
      psnet.ahrq.gov/issue/report-information-technology-and-health-deficiencies-us-nursing-homes
      October 28, 2020 - Study A report of information technology and health deficiencies in U.S. nursing homes. Citation Text: Alexander GL, Madsen RW. A report of information technology and health deficiencies in U.S. nursing homes. J Patient Saf. 2021;17(6):e483-e489. doi:10.1097/pts.0000000000000390. Copy …

8907. Surgical safety and hospital volume across a wide range of interventions. | PSNet
      psnet.ahrq.gov/issue/surgical-safety-and-hospital-volume-across-wide-range-interventions
      April 04, 2011 - Study Surgical safety and hospital volume across a wide range of interventions. Citation Text: Eggli Y, Halfon P, Meylan D, et al. Surgical safety and hospital volume across a wide range of interventions. Med Care. 2010;48(11):962-71. doi:10.1097/MLR.0b013e3181eaf9f6. Copy Citation …

8908. Morning handover of on-call issues: opportunities for improvement. | PSNet
      psnet.ahrq.gov/issue/morning-handover-call-issues-opportunities-improvement
      September 26, 2012 - Study Morning handover of on-call issues: opportunities for improvement. Citation Text: Devlin MK, Kozij NK, Kiss A, et al. Morning handover of on-call issues: opportunities for improvement. JAMA Intern Med. 2014;174(9):1479-85. doi:10.1001/jamainternmed.2014.3033. Copy Citation Fo…

8909. Tool: STEP | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/situation/tools/step.html
      June 01, 2023 - Tool: STEP STEP is a mnemonic tool that can help individuals monitor critical elements of a situation and the overall environment. It is suitable for use by teams supporting acutely ill patients in a hospital (e.g., an ICU patient the team hopes to wean off a ventilator as quickly as possible), for teams in lon…

8910. Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. | PSNet
      psnet.ahrq.gov/issue/risk-adjusted-morbidity-teaching-hospitals-correlates-reported-levels-communication-and
      July 12, 2010 - Study Classic Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. Citation Text: Davenport DL…

8911. The effects of electronic nursing handover on patient safety in the general (non-COVID-19) and COVID-19 intensive care units: a quasi-experimental study. | PSNet
      psnet.ahrq.gov/issue/effects-electronic-nursing-handover-patient-safety-general-non-covid-19-and-covid-19
      February 26, 2020 - Study The effects of electronic nursing handover on patient safety in the general (non-COVID-19) and COVID-19 intensive care units: a quasi-experimental study. Citation Text: Tataei A, Rahimi B, Afshar HL, et al. The effects of electronic nursing handover on patient safety in the general…

8912. Identifying hospital-wide harm: a set of ICD-9–CM-coded conditions associated with increased cost, length of stay, and risk of mortality. | PSNet
      psnet.ahrq.gov/issue/identifying-hospital-wide-harm-set-icd-9-cm-coded-conditions-associated-increased-cost-length
      September 07, 2016 - Study Identifying hospital-wide harm: a set of ICD-9–CM-coded conditions associated with increased cost, length of stay, and risk of mortality. Citation Text: Bankowitz RA, Doyle B, Duan M, et al. Identifying hospital-wide harm: a set of ICD-9-CM-coded conditions associated with increase…

8913. Clinical diagnoses and autopsy findings: discrepancies in critically ill patients. | PSNet
      psnet.ahrq.gov/issue/clinical-diagnoses-and-autopsy-findings-discrepancies-critically-ill-patients
      March 09, 2022 - Study Clinical diagnoses and autopsy findings: discrepancies in critically ill patients. Citation Text: Tejerina E, Esteban A, Fernández-Segoviano P, et al. Clinical diagnoses and autopsy findings: discrepancies in critically ill patients*. Crit Care Med. 2012;40(3):842-6. doi:10.1097/…

8914. Evaluation and comparison of errors on nursing notes created by online and offline speech recognition technology and handwritten: an interventional study. | PSNet
      psnet.ahrq.gov/issue/evaluation-and-comparison-errors-nursing-notes-created-online-and-offline-speech-recognition
      April 13, 2022 - Study Evaluation and comparison of errors on nursing notes created by online and offline speech recognition technology and handwritten: an interventional study. Citation Text: Peivandi S, Ahmadian L, Farokhzadian J, et al. Evaluation and comparison of errors on nursing notes created by o…

8915. Office surgery incidents: what seven years of Florida data show us. | PSNet
      psnet.ahrq.gov/issue/office-surgery-incidents-what-seven-years-florida-data-show-us
      August 19, 2009 - Study Office surgery incidents: what seven years of Florida data show us. Citation Text: Coldiron BM, Healy C, Bene NI. Office surgery incidents: what seven years of Florida data show us. Dermatol Surg. 2008;34(3):285-91; discussion 291-2. doi:10.1111/j.1524-4725.2007.34060.x. Copy C…

8916. Medical errors during training: how do residents cope?: a descriptive study. | PSNet
      psnet.ahrq.gov/issue/medical-errors-during-training-how-do-residents-cope-descriptive-study
      October 13, 2021 - Study Medical errors during training: how do residents cope?: a descriptive study. Citation Text: Fatima S, Soria S, Esteban- Cruciani N. Medical errors during training: how do residents cope?: a descriptive study. BMC Med Educ. 2021;21(1):408. doi:10.1186/s12909-021-02850-1. Copy Cit…

8917. Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions. | PSNet
      psnet.ahrq.gov/issue/comparing-variability-ingredient-strength-and-dose-form-information-electronic-prescriptions
      March 20, 2024 - Study Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions. Citation Text: Lester CA, Flynn AJ, Marshall VD, et al. Comparing the variability of ingredient, strength, and dose form information fro…

8918. Appendix P. Evaluating and Selecting Hand Hygiene Products - Implementation Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-p.html
      May 01, 2017 - Appendix P. Evaluating and Selecting Hand Hygiene Products - Implementation Guide Slide 1: Appendix P. Evaluating and Selecting Hand Hygiene Products Timothy Landers, Ph.D., R.N., CNP, CIC Assistant Professor, The Ohio State University College of Nursing Slide 2: Disclosures Dr. Landers receives sala…

8919. Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department. | PSNet
      psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric-hospital
      June 22, 2017 - Study Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department. Citation Text: Gur-Arieh S, Mendlovic S, Rozenblum R, et al. Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergen…

8920. Assessing patient safety in a pediatric telemedicine setting: a multi-methods study. | PSNet
      psnet.ahrq.gov/issue/assessing-patient-safety-pediatric-telemedicine-setting-multi-methods-study
      May 01, 2024 - Study Emerging Classic Assessing patient safety in a pediatric telemedicine setting: a multi-methods study. Citation Text: Haimi M, Brammli-Greenberg S, Baron-Epel O, et al. Assessing patient safety in a pediatric telemedicine setting: a multi-methods study. BMC…