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psnet.ahrq.gov/issue/information-technology-interventions-improve-medication-safety-primary-care-systematic-review
July 29, 2020 - Review
Information technology interventions to improve medication safety in primary care: a systematic review.
Citation Text:
Lainer M, Mann E, Sönnichsen A. Information technology interventions to improve medication safety in primary care: a systematic review. Int J Qual Health Care. 20…
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psnet.ahrq.gov/issue/interventions-employed-improve-intrahospital-handover-systematic-review
January 20, 2015 - Review
Interventions employed to improve intrahospital handover: a systematic review.
Citation Text:
Robertson ER, Morgan L, Bird S, et al. Interventions employed to improve intrahospital handover: a systematic review. BMJ Qual Saf. 2014;23(7):600-7. doi:10.1136/bmjqs-2013-002309.
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psnet.ahrq.gov/issue/systematic-review-effectiveness-interruptive-medication-prescribing-alerts-hospital-cpoe
August 17, 2016 - Review
A systematic review of the effectiveness of interruptive medication prescribing alerts in hospital CPOE systems to change prescriber behavior and improve patient safety.
Citation Text:
Page N, Baysari MT, Westbrook JI. A systematic review of the effectiveness of interruptive medic…
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psnet.ahrq.gov/issue/understanding-facilitators-and-barriers-care-transitions-insights-project-achieve-site-visits
September 23, 2020 - Study
Classic
Understanding facilitators and barriers to care transitions: insights from Project ACHIEVE Site Visits.
Citation Text:
Scott AM, Li J, Oyewole-Eletu S, et al. Understanding facilitators and barriers to care transitions: insights from Project ACHIEV…
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psnet.ahrq.gov/issue/evaluation-laboratory-monitoring-alerts-within-computerized-physician-order-entry-system
October 06, 2011 - Study
Evaluation of laboratory monitoring alerts within a computerized physician order entry system for medication orders.
Citation Text:
Palen TE, Raebel MA, Lyons E, et al. Evaluation of laboratory monitoring alerts within a computerized physician order entry system for medication o…
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psnet.ahrq.gov/issue/impact-pharmacist-interventions-provided-emergency-department-quality-use-medicines
July 21, 2021 - Review
Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic review and meta-analysis.
Citation Text:
Atey TM, Peterson GM, Salahudeen MS, et al. Impact of pharmacist interventions provided in the emergency department on quality…
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psnet.ahrq.gov/issue/patient-complaints-healthcare-systems-systematic-review-and-coding-taxonomy
November 29, 2023 - Review
Patient complaints in healthcare systems: a systematic review and coding taxonomy.
Citation Text:
Reader TW, Gillespie A, Roberts J. Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf. 2014;23(8):678-689. doi:10.1136/bmjqs-2013-002437. …
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psnet.ahrq.gov/issue/measuring-patient-safety-primary-care-development-and-validation-patient-reported-experiences
April 25, 2018 - Study
Measuring patient safety in primary care: the development and validation of the "Patient Reported Experiences and Outcomes of Safety in Primary Care" (PREOS-PC).
Citation Text:
Ricci-Cabello I, Avery A, Reeves D, et al. Measuring Patient Safety in Primary Care: The Development and …
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psnet.ahrq.gov/issue/association-adverse-effects-medical-treatment-mortality-united-states-secondary-analysis
November 11, 2020 - Study
Association of adverse effects of medical treatment with mortality in the United States: a secondary analysis of the Global Burden of Diseases, Injuries, and Risk Factors study.
Citation Text:
Sunshine JE, Meo N, Kassebaum NJ, et al. Association of Adverse Effects of Medical Treatm…
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psnet.ahrq.gov/issue/workarounds-electronic-health-record-systems-and-revised-sociotechnical-electronic-health
October 05, 2022 - Review
Workarounds in electronic health record systems and the revised Sociotechnical Electronic Health Record Workaround Analysis Framework: scoping review.
Citation Text:
Blijleven V, Hoxha F, Jaspers MWM. Workarounds in electronic health record systems and the revised sociotechnical E…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/141-cusp-tip-sheet-assembling-team.docx
April 01, 2025 - CUSP Tip Sheet:
Assembling the CUSP Team
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Purpose
Teamwork and interprofessional collaboration are important to high-quality patient care. A culture of teamwork and learning from mistakes helps improve patient safety. The Compre…
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psnet.ahrq.gov/issue/feasibility-prospective-error-reporting-home-palliative-care-mixed-methods-study
November 11, 2020 - Study
Feasibility of prospective error reporting in home palliative care: a mixed methods study.
Citation Text:
Kurahashi AM, Kim G, Parry N, et al. Feasibility of prospective error reporting in home palliative care: a mixed methods study. Palliat Med. 2025;39(1):22-30. doi:10.1177/02692…
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psnet.ahrq.gov/issue/comparison-quality-measures-us-hospitals-physician-vs-nonphysician-chief-executive-officers
July 13, 2022 - Study
Comparison of quality measures from US hospitals with physician vs nonphysician chief executive officers.
Citation Text:
See H, Shreve L, Hartzell S, et al. Comparison of quality measures from US hospitals with physician vs nonphysician chief executive officers. JAMA Netw Open. 202…
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www.ahrq.gov/teamstepps-program/curriculum/communication/tools/handoff.html
May 01, 2023 - Tool: Handoff
A handoff is a standardized method for transferring information, along with authority and responsibility, during transitions in patient care. Handoffs include the transfer of knowledge and information about the degree of uncertainty (uncertainty about diagnoses, etc.), response to treatment, recen…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/149-cusp-tip-sheet-assembling-team.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
CUSP Tip Sheet:
Assembling the CUSP Team
ICU & Non-ICU
Purpose
Teamwork and interprofessional collaboration are important to high-quality patient care. A culture of teamwork and learning from mistakes helps improve patient safety. The Comprehensive Unit-based Safety Program (CUS…
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psnet.ahrq.gov/issue/electronic-health-record-related-safety-concerns-cross-sectional-survey
August 03, 2016 - Study
Electronic health record–related safety concerns: a cross-sectional survey.
Citation Text:
Menon S, Singh H, Meyer AND, et al. Electronic health record-related safety concerns: a cross-sectional survey. J Healthc Risk Manag. 2014;34(1):14-26. doi:10.1002/jhrm.21146.
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www.ahrq.gov/talkingquality/explain/numbers.html
November 01, 2018 - Why Aren't Numbers and Graphs Sufficient for a Quality Report?
Quality reports need a brief and compelling explanation of the purpose and value of the information they contain, as well as the trustworthiness of the report’s sponsor. This page discusses why this is necessary.
Quality Information Is New
Som…
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psnet.ahrq.gov/issue/dual-health-care-system-use-and-high-risk-prescribing-patients-dementia-national-cohort-study
July 02, 2019 - Study
Dual health care system use and high-risk prescribing in patients with dementia: a national cohort study.
Citation Text:
Thorpe JM, Thorpe CT, Gellad WF, et al. Dual Health Care System Use and High-Risk Prescribing in Patients With Dementia: A National Cohort Study. Ann Intern Med.…
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psnet.ahrq.gov/issue/standardized-formulary-reduce-pediatric-medication-dosing-errors-mixed-methods-study
August 25, 2021 - Study
A standardized formulary to reduce pediatric medication dosing errors: a mixed methods study.
Citation Text:
Bosson N, Kaji AH, Gausche-Hill M. A standardized formulary to reduce pediatric medication dosing errors: a mixed methods study. Prehosp Emerg Care. 2022;26(4):492-502. doi:…
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psnet.ahrq.gov/issue/exploring-everyday-work-dynamic-non-event-and-adaptations-manage-safety-intraoperative
February 03, 2021 - Study
Exploring everyday work as a dynamic non-event and adaptations to manage safety in intraoperative anaesthesia care: an interview study.
Citation Text:
Olin K, Klinga C, Ekstedt M, et al. Exploring everyday work as a dynamic non-event and adaptations to manage safety in intraoperati…