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5821. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41539/psn-pdf
      January 07, 2015 - Dying for the weekend: a retrospective cohort study on the association between day of hospital presentation and the quality and safety of stroke care. January 7, 2015 Palmer WL, Bottle A, Davie C, et al. Dying for the weekend: a retrospective cohort study on the association between day of hospital presentation and…

5822. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45356/psn-pdf
      May 09, 2017 - Screening for medication errors using an outlier detection system. May 9, 2017 Schiff G, Volk LA, Volodarskaya M, et al. Screening for medication errors using an outlier detection system. J Am Med Inform Assoc. 2017;24(2):281-287. doi:10.1093/jamia/ocw171. https://psnet.ahrq.gov/issue/screening-medication-errors-u…

5823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39142/psn-pdf
      December 02, 2009 - Resident and RN perceptions of the impact of a medical emergency team on education and patient safety in an academic medical center. December 2, 2009 Sarani B, Sonnad SS, Bergey MR, et al. Resident and RN perceptions of the impact of a medical emergency team on education and patient safety in an academic medical c…

5824. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73241/psn-pdf
      May 12, 2021 - Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review. May 12, 2021 Reece JC, Neal EFG, Nguyen P, et al. Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review. BMC Cancer. 2021;21(1):373. doi:10.11…

5825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43341/psn-pdf
      July 23, 2014 - Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients. July 23, 2014 Smeulers M, Lucas C, Vermeulen H. Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients. Cochrane Database of Syst Rev. 2014…

5826. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42711/psn-pdf
      October 31, 2014 - Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units. October 31, 2014 Carayon P, Wetterneck TB, Cartmill R, et al. Characterising the complexity of medication safety using a human factors approach: an observational study in two inten…

5827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44004/psn-pdf
      September 01, 2016 - Impact of computerized physician order entry alerts on prescribing in older patients. September 1, 2016 Lester PE, Rios-Rojas L, Islam S, et al. Impact of computerized physician order entry alerts on prescribing in older patients. Drugs Aging. 2015;32(3):227-33. doi:10.1007/s40266-015-0244-2. https://psnet.ahrq.go…

5828. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44372/psn-pdf
      June 21, 2016 - Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services Hospital- Acquired Condition Reduction Program. June 21, 2016 Rajaram R, Chung JW, Kinnier C, et al. Hospital Characteristics Associated With Penalties in the Centers for Medicare & Medicaid Services Hospital-Acquire…

5829. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36366/psn-pdf
      April 11, 2011 - Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. April 11, 2011 Sharek PJ, Horbar JD, Mason W, et al. Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-foc…

5830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39662/psn-pdf
      April 30, 2014 - Patient record review of the incidence, consequences, and causes of diagnostic adverse events. April 30, 2014 Zwaan L, de Bruijne M, Wagner C, et al. Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Arch Intern Med. 2010;170(12):1015-21. doi:10.1001/archinternmed.2010.…

5831. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39641/psn-pdf
      September 20, 2011 - Adherence to Surgical Care Improvement Project measures and the association with postoperative infections. September 20, 2011 Stulberg JJ, Delaney CP, Neuhauser D, et al. Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA. 2010;303(24):2479-85. doi:10.1…

5832. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46343/psn-pdf
      March 21, 2018 - Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors. March 21, 2018 Hickman T-TT, Quist AJL, Salazar A, et al. Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors. BMJ Qual Saf.…

5833. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43729/psn-pdf
      November 21, 2017 - Medical harm: patient perceptions and follow-up actions. November 21, 2017 Lyu HG, Cooper M, Mayer-Blackwell B, et al. Medical Harm: Patient Perceptions and Follow-up Actions. J Patient Saf. 2017;13(4):199-201. doi:10.1097/PTS.0000000000000136. https://psnet.ahrq.gov/issue/medical-harm-patient-perceptions-and-follo…

5834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41283/psn-pdf
      April 11, 2012 - Clinical diagnoses and autopsy findings: discrepancies in critically ill patients. April 11, 2012 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/CCM.0b013e318236f64f. https://psne…

5835. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45555/psn-pdf
      June 15, 2017 - Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes. June 15, 2017 Sheringham J, Sequeira R, Myles J, et al. Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes. BMJ Qual Saf. 2017;26(6…

5836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47671/psn-pdf
      January 01, 2019 - Racial, ethnic, and socioeconomic disparities in patient safety events for hospitalized children. December 19, 2018 Stockwell DC, Landrigan CP, Toomey SL, et al. Racial, Ethnic, and Socioeconomic Disparities in Patient Safety Events for Hospitalized Children. Hosp Pediatr. 2019;9(1):1-5. doi:10.1542/hpeds.2018-0131…

5837. Failure Mode and Effect Analysis (FMEA) | PSNet
      psnet.ahrq.gov/glossary/failure-mode-and-effect-analysis-fmea
      September 13, 2021 - Failure Mode and Effect Analysis (FMEA) September 13, 2021 Anonymous (not verified) A common process used to prospectively identify error risk within a particular process. FMEA begins with a complete process mapping that identifies all the steps that must occur for a given process to occur (e.g., programming an…

5838. Multi-Vari Chart | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/multi-vari-chart
      January 01, 2023 - Multi-Vari Chart Also Known As Multivariate chart Description A multi-vari chart shows both several sources of variation in addition to the most significant contributors to total variation. Uses When the output has a variable measurement. When attempting to identify the biggest…

5839. About the Toolkit Development | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/cauti-hospitals/toolkit-about.html
      March 01, 2018 - About the Toolkit Development Toolkit for Reducing CAUTI in Hospitals The toolkit was developed as part of a national implementation project to reduce CAUTI in hospitals. The 4-year project brought together subject matter experts and participating hospitals across the country. Background Catheter-associ…

5840. NICU Family Information Packet, Appendix B, Gastroesophageal Reflux (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-ger.pdf
      June 02, 2025 - NICU Family Information Packet, Appendix B, Gastroesophageal Reflux Gastroesophageal Reflux Characteristics ■ Common problem in premature infants. – Lower esophageal sphincter hypotonia. – Transient relaxation of the esophageal sphincter. – Less frequent esophageal peristaltic activity. – Delayed gastric em…