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psnet.ahrq.gov/issue/national-partnership-maternal-safety-consensus-bundle-venous-thromboembolism
November 16, 2022 - Commentary
National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.
Citation Text:
D'Alton ME, Friedman AM, Smiley RM, et al. National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. J Obstet Gynecol Neonatal Nurs. 2016;45(5):706-…
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psnet.ahrq.gov/issue/connected-care-reducing-errors-through-automated-vital-signs-data-upload
September 01, 2018 - Study
Connected care: reducing errors through automated vital signs data upload.
Citation Text:
Smith LB, Banner L, Lozano D, et al. Connected care: reducing errors through automated vital signs data upload. Comput Inform Nurs. 2009;27(5):318-23. doi:10.1097/NCN.0b013e3181b21d65.
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psnet.ahrq.gov/issue/guidelines-us-hospitals-and-clinicians-assessment-electronic-health-record-safety-using-safer
June 24, 2020 - Commentary
Guidelines for US hospitals and clinicians on assessment of electronic health record safety using SAFER Guides.
Citation Text:
Sittig DF, Sengstack P, Singh H. Guidelines for US hospitals and clinicians on assessment of electronic health record safety using SAFER Guides. JAMA.…
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psnet.ahrq.gov/issue/impact-tele-icu-provider-attitudes-about-teamwork-and-safety-climate
May 25, 2016 - Study
The impact of a tele-ICU on provider attitudes about teamwork and safety climate.
Citation Text:
Chu-Weininger MYL, Wueste L, Lucke JF, et al. The impact of a tele-ICU on provider attitudes about teamwork and safety climate. Qual Saf Health Care. 2010;19(6):e39. doi:10.1136/qshc.…
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psnet.ahrq.gov/issue/ins-and-outs-change-shift-handoffs-between-nurses-communication-challenge
October 19, 2022 - Study
The ins and outs of change of shift handoffs between nurses: a communication challenge.
Citation Text:
Carroll JS, Williams M, Gallivan TM. The ins and outs of change of shift handoffs between nurses: a communication challenge. BMJ Qual Saf. 2012;21(7):586-93. doi:10.1136/bmjqs-2…
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psnet.ahrq.gov/issue/fractures-fingers-missed-or-misdiagnosed-poorly-positioned-or-poorly-taken-radiographs
September 07, 2022 - Study
Fractures of the fingers missed or misdiagnosed on poorly positioned or poorly taken radiographs: a retrospective study.
Citation Text:
Tuncer S, Aksu N, Dilek H, et al. Fractures of the fingers missed or misdiagnosed on poorly positioned or poorly taken radiographs: a retrospect…
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psnet.ahrq.gov/issue/overriding-drug-safety-alerts-computerized-physician-order-entry
March 04, 2011 - Review
Overriding of drug safety alerts in computerized physician order entry.
Citation Text:
van der Sijs H, Aarts J, Vulto A, et al. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13(2):138-47.
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psnet.ahrq.gov/issue/lessons-learned-medical-malpractice-claims-involving-critical-care-nurses
July 15, 2020 - Study
Lessons learned from medical malpractice claims involving critical care nurses.
Citation Text:
Myers LC, Heard L, Mort E. Lessons learned from medical malpractice claims involving critical care nurses. Am J Crit Care. 2020;29(3):174-181. doi:10.4037/ajcc2020341.
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psnet.ahrq.gov/issue/quality-improvement-implementation-and-hospital-performance-patient-safety-indicators
January 12, 2022 - Study
Classic
Quality improvement implementation and hospital performance on patient safety indicators.
Citation Text:
Weiner BJ, Alexander JA, Baker LC, et al. Quality improvement implementation and hospital performance on patient safety indicators. Med Care …
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psnet.ahrq.gov/issue/integrating-ethics-and-patient-safety-role-clinical-ethics-consultants-quality-improvement
October 04, 2011 - Commentary
Integrating ethics and patient safety: the role of clinical ethics consultants in quality improvement.
Citation Text:
Opel DJ, Brownstein D, Diekema DS, et al. Integrating ethics and patient safety: the role of clinical ethics consultants in quality improvement. J Clin Ethic…
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psnet.ahrq.gov/issue/novel-process-audit-standardized-perioperative-handoff-protocols
June 27, 2018 - Commentary
A novel process audit for standardized perioperative handoff protocols.
Citation Text:
Pallekonda V, Scholl AT, McKelvey GM, et al. A Novel Process Audit for Standardized Perioperative Handoff Protocols. Jt Comm J Qual Patient Saf. 2017;43(11):611-618. doi:10.1016/j.jcjq.2017.…
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psnet.ahrq.gov/issue/improving-inpatient-mental-health-medication-safety-through-process-obtaining-himss-stage-7
July 17, 2019 - Commentary
Improving inpatient mental health medication safety through the process of obtaining HIMSS Stage 7: a case report.
Citation Text:
Improving inpatient mental health medication safety through the process of obtaining HIMSS Stage 7: a case report. Sulkers H, Tajirian T, Paterson …
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psnet.ahrq.gov/issue/association-between-night-or-weekend-admission-and-hospitalization-relevant-patient-outcomes
November 26, 2014 - Study
The association between night or weekend admission and hospitalization-relevant patient outcomes.
Citation Text:
Khanna R, Wachsberg K, Marouni A, et al. The association between night or weekend admission and hospitalization-relevant patient outcomes. J Hosp Med. 2011;6(1):10-4.…
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psnet.ahrq.gov/issue/learning-failure-need-independent-safety-investigation-healthcare
September 24, 2018 - Commentary
Learning from failure: the need for independent safety investigation in healthcare.
Citation Text:
Macrae C, Vincent CA. Learning from failure: the need for independent safety investigation in healthcare. J R Soc Med. 2014;107(11):439-443. doi:10.1177/0141076814555939.
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psnet.ahrq.gov/issue/computerized-ecg-friend-and-foe
December 04, 2024 - Review
Emerging Classic
The computerized ECG: friend and foe.
Citation Text:
Smulyan H. The Computerized ECG: Friend and Foe. Am J Med. 2019;132(2):153-160. doi:10.1016/j.amjmed.2018.08.025.
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psnet.ahrq.gov/issue/unintentionally-retained-foreign-objects-descriptive-study-308-sentinel-events-and
March 20, 2019 - Study
Emerging Classic
Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors.
Citation Text:
Steelman VM, Shaw C, Shine L, et al. Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentine…
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www.ahrq.gov/news/newsroom/case-studies/201512.html
May 01, 2015 - AHRQ’s RED Toolkit Helps VA Hospitals in California and Texas Lower Readmissions, Improve Discharge Process
Search All Impact Case Studies
May 2015
Thirty-day all-cause hospital readmissions at the Department of Veterans Affairs (VA) Palo Alto (CA) Health Care System dropped 30 percent after administrators …
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psnet.ahrq.gov/issue/copy-paste-and-cloned-notes-electronic-health-records-prevalence-benefits-risks-and-best
October 19, 2022 - Review
Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations.
Citation Text:
Weis JM, Levy PC. Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations. …
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psnet.ahrq.gov/issue/transitional-chaos-or-enduring-harm-ehr-and-disruption-medicine
August 02, 2015 - Commentary
Transitional chaos or enduring harm? The EHR and the disruption of medicine.
Citation Text:
Rosenbaum L. Transitional Chaos or Enduring Harm? The EHR and the Disruption of Medicine. New Engl J Med. 2015;373(17):1585-1588. doi:10.1056/NEJMp1509961.
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psnet.ahrq.gov/issue/comparison-physician-and-computer-diagnostic-accuracy
November 03, 2015 - Study
Comparison of physician and computer diagnostic accuracy.
Citation Text:
Semigran HL, Levine DM, Nundy S, et al. Comparison of Physician and Computer Diagnostic Accuracy. JAMA Intern Med. 2016;176(12):1860-1861. doi:10.1001/jamainternmed.2016.6001.
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