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psnet.ahrq.gov/node/60813/psn-pdf
January 01, 2021 - Medication-related interventions delivered both in
hospital and following discharge: a systematic review and
meta-analysis.
August 19, 2020
Daliri S, Boujarfi S, el Mokaddam A, et al. Medication-related interventions delivered both in hospital and
following discharge: a systematic review and meta-analysis. BMJ Qua…
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psnet.ahrq.gov/node/839812/psn-pdf
November 09, 2022 - Measuring psychological safety and local learning to
enable high reliability organisational change.
November 9, 2022
Cartland J, Green M, Kamm D, et al. Measuring psychological safety and local learning to enable high
reliability organisational change. BMJ Open Qual. 2022;11(4):e001757. doi:10.1136/bmjoq-2021-00175…
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psnet.ahrq.gov/node/843088/psn-pdf
January 25, 2023 - The value of learning from near misses to improve patient
safety: a scoping review.
January 25, 2023
Woodier N, Burnett C, Moppett I. The value of learning from near misses to improve patient safety: a
scoping review. J Patient Saf. 2022;19(1):42-47. doi:10.1097/pts.0000000000001078.
https://psnet.ahrq.gov/issue/v…
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psnet.ahrq.gov/node/46154/psn-pdf
June 07, 2017 - Postoperative opioid prescribing and the pain scores on
Hospital Consumer Assessment of Healthcare Providers
and Systems survey.
June 7, 2017
Lee JS, Hu HM, Brummett CM, et al. Postoperative Opioid Prescribing and the Pain Scores on Hospital
Consumer Assessment of Healthcare Providers and Systems Survey. JAMA. 201…
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psnet.ahrq.gov/node/34677/psn-pdf
February 09, 2011 - Patients' and physicians' attitudes regarding the
disclosure of medical errors.
February 9, 2011
Gallagher TH, Waterman AD, Ebers AG, et al. Patients' and physicians' attitudes regarding the disclosure
of medical errors. JAMA. 2003;289(8):1001-7.
https://psnet.ahrq.gov/issue/patients-and-physicians-attitudes-regar…
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psnet.ahrq.gov/node/74761/psn-pdf
February 09, 2022 - Did the Hospital Readmissions Reduction Program
reduce readmissions? An assessment of prior evidence
and new estimates.
February 9, 2022
Ziedan E, Kaestner R. Did the Hospital Readmissions Reduction Program reduce readmissions? An
assessment of prior evidence and new estimates. Eval Rev. 2021;45(6):359-411.
doi:1…
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psnet.ahrq.gov/node/46252/psn-pdf
September 24, 2017 - Efficiency and interpretability of text paging
communication for medical inpatients: a mixed-methods
analysis.
September 24, 2017
Mandl KD, Khoong EC. Pagers and Beyond in an Era of Microcommunications—What Is Old Is New Again.
JAMA Intern Med. 2017;177(8). doi:10.1001/jamainternmed.2017.2145.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/72478/psn-pdf
November 18, 2020 - The impact of the use of employee functional flexibility on
patient safety.
November 18, 2020
Salvador RO, Gnanlet A, McDermott C. The impact of the use of employee functional flexibility on patient
safety. Personnel Rev. 2020;50(3):971-984. doi:10.1108/pr-10-2019-0562.
https://psnet.ahrq.gov/issue/impact-use-empl…
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psnet.ahrq.gov/node/38993/psn-pdf
January 04, 2010 - Relationship between call light use and response time
and inpatient falls in acute care settings.
January 4, 2010
Tzeng H-M, Yin C-Y. Relationship between call light use and response time and inpatient falls in acute care
settings. J Clin Nurs. 2009;18(23):3333-41. doi:10.1111/j.1365-2702.2009.02916.x.
https://psn…
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psnet.ahrq.gov/node/73472/psn-pdf
July 07, 2021 - Safety checklists for emergency response driving and
patient transport: experiences from emergency medical
services.
July 7, 2021
Jakonen A, Mänty M, Nordquist H. Safety checklists for emergency response driving and patient transport:
experiences from emergency medical services. Jt Comm J Qual Patient Saf. 2021;47…
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psnet.ahrq.gov/node/43257/psn-pdf
August 14, 2014 - Barriers and success factors to the implementation of a
multi-site prospective adverse event surveillance system.
August 14, 2014
Backman C, Forster AJ, Vanderloo S. Barriers and success factors to the implementation of a multi-site
prospective adverse event surveillance system. Int J Qual Health Care. 2014;26(4):4…
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psnet.ahrq.gov/node/60736/psn-pdf
July 29, 2020 - Use of an electronic decision support tool to reduce
polypharmacy in elderly people with chronic diseases:
cluster randomised controlled trial.
July 29, 2020
Rieckert A, Reeves D, Altiner A, et al. Use of an electronic decision support tool to reduce polypharmacy in
elderly people with chronic diseases: cluster ra…
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psnet.ahrq.gov/node/73987/psn-pdf
October 20, 2021 - Impact of clinical decision support therapeutic
interchanges on hospital discharge medication omissions
and duplications.
October 20, 2021
Maxwell E, Amerine J, Carlton G, et al. Impact of clinical decision support therapeutic interchanges on
hospital discharge medication omissions and duplications. Am J Health Sy…
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psnet.ahrq.gov/node/73373/psn-pdf
January 01, 2022 - State medical board regulation of compounding in
physician offices.
June 9, 2021
Reynolds KA, Hellquist K, Ibrahim SA, et al. State medical board regulation of compounding in physician
offices. Arch Dermatol Res. 2022;314(4):363-367. doi:10.1007/s00403-021-02237-8.
https://psnet.ahrq.gov/issue/state-medical-board-…
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psnet.ahrq.gov/node/837894/psn-pdf
August 24, 2022 - Identifying boundary spanning reporter roles in patient
safety events.
August 24, 2022
Hurley VB, Boxley C, Sloss EA, et al. Identifying boundary spanning reporter roles in patient safety events.
J Patient Saf Risk Manag. 2022;27(4):181-187. doi:10.1177/25160435221103096.
https://psnet.ahrq.gov/issue/identifying-b…
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psnet.ahrq.gov/node/837149/psn-pdf
May 18, 2022 - Human factors analysis of latent safety threats in a
pediatric critical care unit.
May 18, 2022
Trbovich PL, Tomasi JN, Kolodzey L, et al. Human factors analysis of latent safety threats in a pediatric
critical care unit. Pediatr Crit Care Med. 2022;23(3):151-159. doi:10.1097/pcc.0000000000002832.
https://psnet.ah…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-4.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 4.4. Chronology of Quality Improvement and Lean at Suntown Hospital
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakev…
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psnet.ahrq.gov/node/837893/psn-pdf
August 24, 2022 - Exploring nurses' attitudes, skills, and beliefs of
medication safety practices.
August 24, 2022
Arkin L, Schuermann A, Penoyer D, et al. Exploring nurses' attitudes, skills, and beliefs of medication
safety practices. J Nurs Care Qual. 2022;37(4):319-326. doi:10.1097/ncq.0000000000000635.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/854246/psn-pdf
October 04, 2023 - Inpatient EHR user experience and hospital EHR safety
performance.
October 4, 2023
Classen DC, Longhurst CA, Davis T, et al. Inpatient EHR user experience and hospital EHR safety
performance. JAMA Netw Open. 2023;6(9):e2333152. doi:10.1001/jamanetworkopen.2023.33152.
https://psnet.ahrq.gov/issue/inpatient-ehr-user…
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psnet.ahrq.gov/node/73092/psn-pdf
March 31, 2021 - SAFER Care: improving caregiver comprehension of
discharge instructions.
March 31, 2021
Uong A, Philips K, Hametz P, et al. SAFER care: improving caregiver comprehension of discharge
instructions. Pediatrics. 2021;147(4):e20200031. doi:10.1542/peds.2020-0031.
https://psnet.ahrq.gov/issue/safer-care-improving-careg…