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psnet.ahrq.gov/issue/limits-knowledge-management-uk-public-services-modernization-case-patient-safety-and-service
January 29, 2014 - Study
The limits of knowledge management for UK public services modernization: the case of patient safety and service quality.
Citation Text:
Currie G, Waring J, Finn R. THE LIMITS OF KNOWLEDGE MANAGEMENT FOR UK PUBLIC SERVICES MODERNIZATION: THE CASE OF PATIENT SAFETY AND SERVICE QUAL…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/study.html
May 01, 2017 - Appendix K. Quality Improvement Study Framework - Implementation Guide
Study Elements
Element
Definition
Things To Keep in Mind
The Purpose
Define the problem and why it is important.
Avoid suggesting causes in the purpose statement. Cause determination will come later afte…
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psnet.ahrq.gov/issue/preventable-harm-canadian-organ-donation-and-transplantation-system-descriptive-study-missed
October 19, 2022 - Study
Preventable harm in the Canadian organ donation and transplantation system: a descriptive study of missed organ donor identification and referral.
Citation Text:
Zavalkoff S, O’Donnell S, Lalani J, et al. Preventable harm in the Canadian organ donation and transplantation system: a…
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psnet.ahrq.gov/issue/value-assessment-deprescribing-interventions-suggestions-improvement
August 04, 2021 - Commentary
Value assessment of deprescribing interventions: suggestions for improvement.
Citation Text:
Hung A, Wang J, Moriarty F, et al. Value assessment of deprescribing interventions: suggestions for improvement. J Am Geriatr Soc. 2023;71(6):2023-2027. doi:10.1111/jgs.18298.
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www.ahrq.gov/sops/about/index.html
July 01, 2024 - About the SOPS Program
Since 2001, the AHRQ Surveys on Patient Safety Culture® (SOPS®) Program has supported AHRQ's mission by advancing the scientific understanding of patient safety culture in healthcare settings. What Is Patient Safety Culture? Patient safety culture is an aspect of an organization's cultu…
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psnet.ahrq.gov/issue/occurrence-wrong-site-surgery-self-reported-candidates-certification-american-board
June 03, 2020 - Study
The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery.
Citation Text:
James MA, Seiler JG, Harrast JJ, et al. The occurrence of wrong-site surgery self-reported by candidates for certification by the Americ…
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psnet.ahrq.gov/issue/intensive-care-units-communication-between-nurses-and-physicians-and-patients-outcomes
May 28, 2008 - Study
Intensive care units, communication between nurses and physicians, and patients' outcomes.
Citation Text:
Manojlovich M, Antonakos CL, Ronis DL. Intensive care units, communication between nurses and physicians, and patients' outcomes. Am J Crit Care. 2009;18(1):21-30. doi:10.403…
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psnet.ahrq.gov/issue/quality-and-patient-safety-improvement-never-finished
September 18, 2024 - Study
Quality and patient safety improvement is never finished.
Citation Text:
Kachalia A, Vanhaecht K. Quality and patient safety improvement is never finished. NEJM Catalyst. 2024;5(9). doi:10.1056/cat.24.0316.
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Format:
DOI Google Scholar BibTeX EndNote X3 XM…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap3a.html
October 01, 2014 - Improving Patient Safety in Long-Term Care Facilities
Appendix 3-A. Suggested Slides for Module 3
Previous Page Next Page
Table of Contents
Improving Patient Safety in Long-Term Care Facilities
Introduction
Module 1. Detecting Change in a Resident's Condition
Module 2. Communicating Change in …
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psnet.ahrq.gov/issue/elephant-patient-safety-what-you-see-depends-how-you-look
June 22, 2022 - Commentary
Classic
The elephant of patient safety: what you see depends on how you look.
Citation Text:
Shojania KG. The elephant of patient safety: what you see depends on how you look. Jt Comm J Qual Patient Saf. 2010;36(9):399-401.
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Format:…
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digital.ahrq.gov/health-care-theme/telehealth
January 01, 2023 - Telehealth
Patient Intestinal Failure-ECHO Project (PIF-ECHO)
Description
This study will evaluate the feasibility and effectiveness of providing chronic intestinal failure patients and their family caregivers with direct access to live, virtual, multi-disciplinary (multi-D) s…
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www.ahrq.gov/cahps/surveys-guidance/home/index.html
November 01, 2023 - CAHPS Home Health Care Survey
The CAHPS Home Health Care Survey asks patients who receive home healthcare services about their experiences with home healthcare agencies, providers, and staff. This instrument focuses on patients who receive skilled home healthcare services from Medicare-certified Home Health Age…
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psnet.ahrq.gov/issue/limits-safety-organizations-accidents-and-nuclear-weapons
July 28, 2013 - Book/Report
Classic
The Limits of Safety: Organizations, Accidents and Nuclear Weapons.
Citation Text:
The Limits of Safety: Organizations, Accidents and Nuclear Weapons. Sagan SD. Princeton NJ: Princeton University Press; 1993. ISBN: 9780691032214.
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psnet.ahrq.gov/issue/telehealth-covid-19-era-balancing-act-avoid-harm
September 28, 2010 - Commentary
Classic
Telehealth in the COVID-19 era: a balancing act to avoid harm.
Citation Text:
Reeves JJ, Ayers JW, Longhurst CA. Telehealth in the COVID-19 Era: a balancing act to avoid harm. J Med Internet Res. 2021;23(2):e24785. doi:10.2196/24785.
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psnet.ahrq.gov/issue/how-will-state-medical-boards-handle-cases-involving-disclosure-and-apology-medical-errors
September 07, 2022 - Study
How will state medical boards handle cases involving disclosure and apology for medical errors?
Citation Text:
Wojcieszak D. How will state medical boards handle cases involving disclosure and apology for medical errors? J Patient Saf Risk Manag. 2022;27(1):15-20. doi:10.1177/25160…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/experience-research/byrne-jm-et
January 01, 2023 - Byrne JM et al. 2009 "Initial experience with patient-clinician secure messaging at a VA medical center."
Reference
Byrne JM, Elliott S, Firek A. Initial experience with patient-clinician secure messaging at a VA medical center. J Am Med Inform Assoc 2009;16(2):267-270.
[Link]
Abstract
"The …
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psnet.ahrq.gov/issue/health-system-resilience-accreditation-high-quality-care-and-continuous-quality-improvement
November 25, 2020 - Commentary
Health system resilience, accreditation, high-quality care, and continuous quality improvement: what is the destination and how do we get there?
Citation Text:
Nicklin W, Greenfield D. Health system resilience, accreditation, high-quality care, and continuous quality improveme…
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psnet.ahrq.gov/issue/differential-diagnosis-checklists-reduce-diagnostic-error-differentially-randomised
September 23, 2020 - Study
Differential diagnosis checklists reduce diagnostic error differentially: a randomised experiment.
Citation Text:
Kämmer JE, Schauber SK, Hautz SC, et al. Differential diagnosis checklists reduce diagnostic error differentially: a randomised experiment. Med Educ. 2021;55(10):1172-1…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/perinatal/chipra-mc4-fullreport.pdf
July 01, 2016 - AMA-convened Physician Consortium for Performance Improvement®
(PCPI™) is a national, physician-led initiative
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cds.ahrq.gov/sites/default/files/cds/artifact/1061/CDS%20Connect_Year%203%20Pilot%20Report_Final.pdf
September 01, 2019 - via a pilot partnership was viewed as an optimal opportunity to
gain a “leg up” on executing a QI initiative