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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit1-10.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 1.10. Lean Projects Studied at LHC
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Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare
Case 2. Central …
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psnet.ahrq.gov/node/47061/psn-pdf
July 25, 2018 - Technical rationality and the decentring of patients and
care delivery: a critique of 'unavoidable' in the context of
patient harm.
July 25, 2018
Hutchinson M, Jackson D, Wilson S. Technical rationality and the decentring of patients and care delivery:
A critique of 'unavoidable' in the context of patient harm. Nu…
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psnet.ahrq.gov/node/34594/psn-pdf
January 04, 2017 - John M. Eisenberg Patient Safety Awards. The Leapfrog
Group for Patient Safety: rewarding higher standards.
January 4, 2017
Eikel C, Delbanco S. John M. Eisenberg Patient Safety Awards. The Leapfrog Group for Patient Safety:
rewarding higher standards. Jt Comm J Qual Saf. 2003;29(12):634-9.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/837744/psn-pdf
July 27, 2022 - Medication orders with future start dates: how far away is
too far?
July 27, 2022
ISMP Medication Safety Alert! Acute care edition. July 14, 2022:27(14):1-4.
https://psnet.ahrq.gov/issue/medication-orders-future-start-dates-how-far-away-too-far
Human errors that occur while interacting with electronic health recor…
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psnet.ahrq.gov/node/46360/psn-pdf
October 25, 2017 - Creating a culture of caregiver support.
October 25, 2017
Gold KJ, Andrew LB, Goldman EB, et al. “I would never want to have a mental health diagnosis on my
record”: A survey of female physicians on mental health diagnosis, treatment, and reporting. General
Hospital Psychiatry. 2016;43. doi:10.1016/j.genhosppsych.2…
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psnet.ahrq.gov/node/43045/psn-pdf
August 02, 2015 - A multistep approach to improving biopsy site
identification in dermatology: physician, staff, and patient
roles based on a Delphi consensus.
August 2, 2015
Alam M, Lee A, Ibrahimi OA, et al. A multistep approach to improving biopsy site identification in
dermatology: physician, staff, and patient roles based on a…
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psnet.ahrq.gov/node/38663/psn-pdf
May 27, 2009 - Prevention of retained surgical sponges: a decision-
analytic model predicting relative cost-effectiveness.
May 27, 2009
Regenbogen SE, Greenberg CC, Resch SC, et al. Prevention of retained surgical sponges: a decision-
analytic model predicting relative cost-effectiveness. Surgery. 2009;145(5):527-35.
doi:10.1016…
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psnet.ahrq.gov/node/37794/psn-pdf
February 15, 2011 - Using staff perceptions on patient safety as a tool for
improving safety culture in a pediatric hospital system.
February 15, 2011
Edwards PJ, Scott T, Richardson P, et al. Using Staff Perceptions on Patient Safety as a Tool for Improving
Safety Culture in a Pediatric Hospital System. J Patient Saf. 2009;4(2). doi:…
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psnet.ahrq.gov/node/47801/psn-pdf
May 11, 2019 - Opioid prescribing trends and the physician’s role in
responding to the public health crisis.
May 11, 2019
Adams JM, Giroir BP. Opioid Prescribing Trends and the Physician's Role in Responding to the Public
Health Crisis. JAMA Intern Med. 2019;179(4):476-478. doi:10.1001/jamainternmed.2018.7934.
https://psnet.ahrq…
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psnet.ahrq.gov/node/74042/psn-pdf
November 03, 2021 - An Investigation into the Death of Baby J at University
Hospitals Bristol and Weston NHS Foundation Trust.
November 3, 2021
Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021.
https://psnet.ahrq.gov/issue/investigation-death-baby-j-university-hospitals-bristol-and-weston-nhs-
foundation-trust…
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psnet.ahrq.gov/node/44440/psn-pdf
August 26, 2015 - Medical costs of Alzheimer's disease misdiagnosis
among US Medicare beneficiaries.
August 26, 2015
Hunter CA, Kirson NY, Desai U, et al. Medical costs of Alzheimer's disease misdiagnosis among US
Medicare beneficiaries. Alzheimers Dement. 2015;11(8):887-95. doi:10.1016/j.jalz.2015.06.1889.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/44918/psn-pdf
April 13, 2016 - National Reporting and Learning System Research and
Development.
April 13, 2016
Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research
Centre; 2016.
https://psnet.ahrq.gov/issue/national-reporting-and-learning-system-research-and-development
Incident reporting has a…
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pso.ahrq.gov/pso/alliance-dedicated-cancer-centers-patient-safety-organization
June 14, 2022 - SHARE:
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Alliance of Dedicated Cancer Centers Patient Safety Organization
PSO Number: P0240 Components of Parent Org(s):
Alliance of Ded…
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psnet.ahrq.gov/node/41392/psn-pdf
July 02, 2014 - Exploring error in team-based acute care scenarios: an
observational study from the United Kingdom.
July 2, 2014
Tallentire VR, Smith SE, Skinner J, et al. Exploring error in team-based acute care scenarios: an
observational study from the United kingdom. Acad Med. 2012;87(6):792-8.
doi:10.1097/ACM.0b013e318253c9e…
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psnet.ahrq.gov/node/74032/psn-pdf
November 03, 2021 - Patient, surgeon, and health care worker safety during the
COVID-19 pandemic.
November 3, 2021
Hölscher AH. Patient, surgeon, and health care worker safety during the COVID-19 pandemic. Ann Surg.
2021;274(5):681-687. doi:10.1097/sla.0000000000005124.
https://psnet.ahrq.gov/issue/patient-surgeon-and-health-care-wor…
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psnet.ahrq.gov/node/44908/psn-pdf
June 07, 2016 - Speak up! Addressing the paradox plaguing patient-
centered care.
June 7, 2016
Mazor KM, Smith KM, Fisher K, et al. Speak Up! Addressing the Paradox Plaguing Patient-Centered Care.
Ann Intern Med. 2016;164(9):618-9. doi:10.7326/M15-2416.
https://psnet.ahrq.gov/issue/speak-addressing-paradox-plaguing-patient-center…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/index.html
November 01, 2021 - Long-term Care Resources
Toolkits, recommendations, and other resources for long-term care facilities to improve quality, reduce errors, and increase patient safety.
Sign up: Long-Term Care Email updates
Comparative Effectiveness Reviews
Comparative effectiveness reviews about long-term care
Evidence …
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www.ahrq.gov/talkingquality/assess/index.html
September 01, 2019 - Assess Your Health Care Quality Reporting Project
Reporting comparative quality information to consumers is typically not a one-time event but an ongoing activity. For this reason, evaluation is a key part of your work, an aspect that has to be thought about and, in some cases, acted upon from the outset.
An …
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psnet.ahrq.gov/node/43967/psn-pdf
November 16, 2015 - Equipped: overcoming barriers to change to improve
quality of care (theories of change).
November 16, 2015
Lachman P, Runnacles J, Dudley J, et al. Equipped: overcoming barriers to change to improve quality of
care (theories of change). Arch Dis Child Educ Pract Ed. 2015;100(1):13-8. doi:10.1136/archdischild-2013-
…
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psnet.ahrq.gov/node/35553/psn-pdf
July 03, 2013 - Maximizing the Use of State Adverse Event Data to
Improve Patient Safety.
July 3, 2013
Rosenthal J, Booth M. National Academy for State Health Policy; 2005.
https://psnet.ahrq.gov/issue/maximizing-use-state-adverse-event-data-improve-patient-safety
This report, generated by the National Academy for State Health Po…