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8521. Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. | PSNet
      psnet.ahrq.gov/issue/reducing-rate-catheter-associated-bloodstream-infections-surgical-intensive-care-unit-using
      November 16, 2022 - Study Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. Citation Text: Sacks GD, Diggs BS, Hadjizacharia P, et al. Reducing the rate of catheter-associated bloodstream infe…

8522. Applying human factors engineering to address the telemetry alarm problem in a large medical center. | PSNet
      psnet.ahrq.gov/issue/applying-human-factors-engineering-address-telemetry-alarm-problem-large-medical-center
      February 10, 2021 - Study Applying human factors engineering to address the telemetry alarm problem in a large medical center. Citation Text: Patterson ES, Rayo MF, Edworthy JR, et al. Applying human factors engineering to address the telemetry alarm problem in a large medical center. Hum Factors. 2022;64(1…

8523. Disclosure-and-resolution programs that include generous compensation offers may prompt a complex patient response. | PSNet
      psnet.ahrq.gov/issue/disclosure-and-resolution-programs-include-generous-compensation-offers-may-prompt-complex
      November 20, 2024 - Study Disclosure-and-resolution programs that include generous compensation offers may prompt a complex patient response. Citation Text: Murtagh L, Gallagher TH, Andrew P, et al. Disclosure-and-resolution programs that include generous compensation offers may prompt a complex patient r…

8524. Impact of medication reconciliation for improving transitions of care. | PSNet
      psnet.ahrq.gov/issue/impact-medication-reconciliation-improving-transitions-care
      June 19, 2019 - Review Emerging Classic Impact of medication reconciliation for improving transitions of care. Citation Text: Redmond P, Grimes TC, McDonnell R, et al. Impact of medication reconciliation for improving transitions of care. Cochrane Database Syst Rev. 2018;8(8):C…

8525. Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. | PSNet
      psnet.ahrq.gov/issue/unintended-discontinuation-medication-following-hospitalisation-retrospective-cohort-study
      September 05, 2018 - Study Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. Citation Text: Redmond P, McDowell R, Grimes TC, et al. Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. BMJ Open. 2019;9(6):e024747. d…

8526. Medication reconciliation failures in children and young adults with chronic disease during intensive and intermediate care. | PSNet
      psnet.ahrq.gov/issue/medication-reconciliation-failures-children-and-young-adults-chronic-disease-during-intensive
      June 22, 2022 - Study Medication reconciliation failures in children and young adults with chronic disease during intensive and intermediate care. Citation Text: DeCourcey DD, Silverman M, Chang E, et al. Medication reconciliation failures in children and young adults with chronic disease during intensi…

8527. Evaluating the Results of a Quality Reporting Project | Agency for Healthcare Research and Quality
      www.ahrq.gov/talkingquality/assess/what-you-evaluate/results.html
      November 01, 2018 - Evaluating the Results of a Quality Reporting Project The purpose of results- or outcome-oriented evaluation goes beyond answering the “did it work” question. To evaluate results, however, you have to be clear about what you wanted to achieve. What consumer audience were you trying to reach? What changes …

8528. Making Adjustments to Health Care Quality Scores | Agency for Healthcare Research and Quality
      www.ahrq.gov/talkingquality/translate/scores/adjustment-scoring.html
      January 01, 2023 - Making Adjustments to Health Care Quality Scores One of the most thorny topics in quality measurement is the adjustment of scores across different plans or providers to account for differences in the characteristics of their patients or themselves. This page reviews key issues related to adjustments to scores…

8529. Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. | PSNet
      psnet.ahrq.gov/issue/distractions-cardiac-catheterisation-laboratory-impact-cardiologists-and-patient-safety
      June 07, 2023 - Study Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. Citation Text: Mahadevan K, Cowan E, Kalsi N, et al. Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. Open Heart. 2020;7(2). doi:…

8530. Measurement of harms in community care: a qualitative study of use of the NHS Safety Thermometer. | PSNet
      psnet.ahrq.gov/issue/measurement-harms-community-care-qualitative-study-use-nhs-safety-thermometer
      January 23, 2019 - Study Measurement of harms in community care: a qualitative study of use of the NHS Safety Thermometer. Citation Text: Brewster L, Tarrant C, Willars J, et al. Measurement of harms in community care: a qualitative study of use of the NHS Safety Thermometer. BMJ Qual Saf. 2018;27(8):625-6…

8531. Measuring the overall development of patient safety in a new hospital using trigger tools. | PSNet
      psnet.ahrq.gov/issue/measuring-overall-development-patient-safety-new-hospital-using-trigger-tools
      April 12, 2019 - Study Measuring the overall development of patient safety in a new hospital using trigger tools. Citation Text: Adamovic I, Dahlem P, Brachmann J. Measuring the overall development of patient safety in a new hospital using trigger tools. Int J Qual Health Care. 2024;36(3):mzae064. doi:10…

8532. Exploring the relationship between hospital patient safety culture and performance on measures of hospital-acquired conditions. | PSNet
      psnet.ahrq.gov/issue/exploring-relationship-between-hospital-patient-safety-culture-and-performance-measures
      August 28, 2024 - Commentary Exploring the relationship between hospital patient safety culture and performance on measures of hospital-acquired conditions. Citation Text: Noghrehchi P, Hefner JL, Stegall H, et al. Exploring the relationship between hospital patient safety culture and performance on measu…

8533. The effect of resident duty hour restriction on trauma center outcomes in teaching hospitals in the state of Pennsylvania. | PSNet
      psnet.ahrq.gov/issue/effect-resident-duty-hour-restriction-trauma-center-outcomes-teaching-hospitals-state
      September 12, 2016 - Study The effect of resident duty hour restriction on trauma center outcomes in teaching hospitals in the state of Pennsylvania. Citation Text: Helling TS, Kaswan S, Boccardo J, et al. The effect of resident duty hour restriction on trauma center outcomes in teaching hospitals in the st…

8534. Understanding SOPS® Surveys: A Primer for New Users - Famolaro (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops-101-webcast-databases.pdf
      January 01, 2022 - Understanding SOPS® Surveys: A Primer for New Users - Famolaro The SOPS Databases Theresa Famolaro, MPS, MS, MBA Senior Study Director User Network for the AHRQ Surveys on Patient Safety Culture (SOPS) Westat SOPS Databases 320 Hospitals Version 1.0 (2021) 172 Hospitals Version 2.0 (2021) 191 Nur…

8535. Prevalence of and factors associated with patient nondisclosure of medically relevant information to clinicians. | PSNet
      psnet.ahrq.gov/issue/prevalence-and-factors-associated-patient-nondisclosure-medically-relevant-information
      May 31, 2017 - Study Emerging Classic Prevalence of and factors associated with patient nondisclosure of medically relevant information to clinicians. Citation Text: Levy AG, Scherer AM, Zikmund-Fisher BJ, et al. Prevalence of and Factors Associated With Patient Nondisclosure …

8536. Application of a digital quality measure for cancer diagnosis in Epic Cosmos. | PSNet
      psnet.ahrq.gov/issue/application-digital-quality-measure-cancer-diagnosis-epic-cosmos
      November 13, 2024 - Study Application of a digital quality measure for cancer diagnosis in Epic Cosmos. Citation Text: Zimolzak AJ, Khan SP, Singh H, et al. Application of a digital quality measure for cancer diagnosis in Epic Cosmos. J Am Med Inform Assoc. 2025;32(1):227-229. doi:10.1093/jamia/ocae253. C…

8537. Biased language in simulated handoffs and clinician recall and attitudes. | PSNet
      psnet.ahrq.gov/issue/biased-language-simulated-handoffs-and-clinician-recall-and-attitudes
      June 29, 2022 - Study Biased language in simulated handoffs and clinician recall and attitudes. Citation Text: Wesevich A, Langan E, Fridman I, et al. Biased language in simulated handoffs and clinician recall and attitudes. JAMA Netw Open. 2024;7(12):e2450172. doi:10.1001/jamanetworkopen.2024.50172. …

8538. Predictors of nursing home nurses' willingness to report medication near-misses. | PSNet
      psnet.ahrq.gov/issue/predictors-nursing-home-nurses-willingness-report-medication-near-misses
      July 31, 2024 - Study Predictors of nursing home nurses' willingness to report medication near-misses. Citation Text: Farag A, Vogelsmeier A, Knox K, et al. Predictors of nursing home nurses' willingness to report medication near-misses. J Gerontol Nurs. 2020;46(4):21-30. doi:10.3928/00989134-20200303-0…

8539. Improving Pediatric Donor Heart Utilization with Predictive Analytics | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/improving-pediatric-donor-heart-utilization-predictive-analytics
      September 30, 2024 - Improving Pediatric Donor Heart Utilization with Predictive Analytics Project Description Integrating predictive risk models and decision aids for clinicians to assess the likelihood of successful pediatric heart transplants in real-time can reduce waitlist mortality, lower don…

8540. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. | PSNet
      psnet.ahrq.gov/issue/incidence-adverse-events-and-negligence-hospitalized-patients-results-harvard-medical
      February 18, 2011 - Study Classic Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. Citation Text: Brennan TA, Leape LL, Laird NM, et al. Incidence of Adverse Events and Negligence in Hospitalized Patients. N Eng…