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psnet.ahrq.gov/issue/understanding-how-rapid-response-systems-may-improve-safety-acutely-ill-patient-learning
July 08, 2015 - Study
Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the frontline.
Citation Text:
Mackintosh N, Rainey H, Sandall J. Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the front…
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www.ahrq.gov/evidencenow/projects/heart-health/evidence/smoking.html
March 01, 2021 - Smoking Cessation Evidence and Resources
About 42 million people in the United States (nearly 18 percent of the population) currently smoke. Tobacco use is a leading cause of illness, disability, and death in the United States. Cigarette smoking accounts for one out of every five deaths and is estimated to incr…
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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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psnet.ahrq.gov/issue/impact-perioperative-catastrophes-anesthesiologists-results-national-survey
August 27, 2009 - Study
The impact of perioperative catastrophes on anesthesiologists: results of a national survey.
Citation Text:
Gazoni FM, Amato PE, Malik ZM, et al. The impact of perioperative catastrophes on anesthesiologists: results of a national survey. Anesth Analg. 2012;114(3):596-603. doi:10…
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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/use-novel-electronic-health-record-centered-interprofessional-icu-rounding-simulation
March 04, 2019 - Study
Use of a novel, electronic health record–centered, interprofessional ICU rounding simulation to understand latent safety issues.
Citation Text:
Bordley J, Sakata KK, Bierman J, et al. Use of a Novel, Electronic Health Record-Centered, Interprofessional ICU Rounding Simulation to Un…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/031-hand-hygiene-monitoring.docx
October 01, 2024 - Direct Observation: Covert1-4
Incorporates unknown or undercover (“secret shopper”) observers to facilitate accurate data collection
Advantages
Disadvantages
· Minimizes the Hawthorne effect—the observer’s effect on the behavior being observed
· Identifies trends and barriers to adherence
· Includes possibility t…
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psnet.ahrq.gov/issue/nurses-perceptions-patient-safety-climate-intensive-care-units-cross-sectional-study
April 14, 2021 - Study
Nurses' perceptions of patient safety climate in intensive care units: a cross-sectional study.
Citation Text:
Ballangrud R, Hedelin B, Hall-Lord ML. Nurses' perceptions of patient safety climate in intensive care units: a cross-sectional study. Intensive Crit Care Nurs. 2012;28(6…
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psnet.ahrq.gov/issue/learning-patient-safety-incidents-green-cross-method
June 14, 2023 - Study
Learning from patient safety incidents: The Green Cross method.
Citation Text:
Jacobsen HK, Ballangrud R, Birkeli GH. Learning from patient safety incidents: the Green Cross method. Nurs Crit Care. 2024;Epub Jun 26. doi:10.1111/nicc.13114.
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Format:
DOI Go…
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www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/appb.html
August 01, 2022 - Demonstration Grants Final Evaluation Report
Appendix B. References
Previous Page
Table of Contents
Demonstration Grants Final Evaluation Report
Executive Summary
Detailed Findings
Evaluation Issues
Contributions to Patient Safety and Medical Liability
Lessons Learned From Implementati…
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psnet.ahrq.gov/issue/iatrogenic-illness-general-medical-service-university-hospital
August 17, 2017 - Study
Classic
Iatrogenic illness on a general medical service at a university hospital.
Citation Text:
Steel K, Gertman PM, Crescenzi C, et al. Iatrogenic illness on a general medical service at a university hospital. N Engl J Med. 1981;304(11):638-42.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/sheridan_screening_overuse.pdf
January 01, 2014 - Understanding and Reducing Overuse of Potentially Harmful Screening Tests
Research Centers for Excellence
in Clinical Preventive Services
Working to get the right services, to the right people, at the right time
Understanding and Reducing Overuse of Potentially Harmful
Screening Tes…
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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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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/clinical-impact-intraoperative-electronic-health-record-downtime-surgical-patients
March 14, 2016 - Study
Clinical impact of intraoperative electronic health record downtime on surgical patients.
Citation Text:
Harrison AM, Siwani R, Pickering BW, et al. Clinical impact of intraoperative electronic health record downtime on surgical patients. J Am Med Inform Assoc. 2019;26(10):928-933.…
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www.ahrq.gov/policymakers/chipra/demoeval/demostates/wy.html
March 01, 2019 - State at a Glance: Wyoming
Learn more about the CHIPRA quality demonstration projects being implemented in Wyoming.
Wyoming is featured in the following reports from the National Evaluation:
Evaluation Highlight No. 6 : How are CHIPRA quality demonstration States working together to improve the quality …
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psnet.ahrq.gov/issue/frequency-and-characteristics-errors-artificial-intelligence-ai-reading-screening-mammography
February 03, 2016 - Review
Frequency and characteristics of errors by artificial intelligence (AI) in reading screening mammography: a systematic review.
Citation Text:
Zeng A, Houssami N, Noguchi N, et al. Frequency and characteristics of errors by artificial intelligence (AI) in reading screening mammogra…
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psnet.ahrq.gov/issue/hospital-implementation-computerized-provider-order-entry-systems-results-2003-leapfrog-group
November 21, 2021 - Study
Hospital implementation of computerized provider order entry systems: results from the 2003 Leapfrog Group quality and safety survey.
Citation Text:
Hillman JM, Given RS. Hospital implementation of computerized provider order entry systems: results from the 2003 leapfrog group qu…
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psnet.ahrq.gov/issue/adapting-rapid-assessment-procedures-implementation-research-using-team-based-approach
November 09, 2022 - Study
Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: a case example of patient quality and safety interventions in the ICU.
Citation Text:
Holdsworth LM, Safaeinili N, Winget M, et al. Adapting rapid assessment procedures for imp…
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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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