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psnet.ahrq.gov/issue/unintended-adverse-consequences-introducing-electronic-health-records-residential-aged-care
March 24, 2019 - Study
Unintended adverse consequences of introducing electronic health records in residential aged care homes.
Citation Text:
Yu P, Zhang Y, Gong Y, et al. Unintended adverse consequences of introducing electronic health records in residential aged care homes. Int J Med Inform. 2013;82…
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psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents
August 25, 2021 - Commentary
Classic
Human error and the problem of causality in analysis of accidents.
Citation Text:
Rasmussen J. Human error and the problem of causality in analysis of accidents. Philos Trans R Soc Lond B Biol Sci. 1990;327(1241):449-462.
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psnet.ahrq.gov/issue/educator-toolkits-second-victim-syndrome-mindfulness-and-meditation-and-positive-psychology
June 28, 2023 - Commentary
Educator toolkits on second victim syndrome, mindfulness and meditation, and positive psychology: the 2017 Resident Wellness Consensus Summit.
Citation Text:
Chung AS, Smart J, Zdradzinski M, et al. Educator Toolkits on Second Victim Syndrome, Mindfulness and Meditation, and P…
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psnet.ahrq.gov/issue/frequency-and-risk-factors-medication-errors-pharmacists-during-order-verification-tertiary
January 23, 2013 - Study
Frequency of and risk factors for medication errors by pharmacists during order verification in a tertiary care medical center.
Citation Text:
Gorbach C, Blanton L, Lukawski BA, et al. Frequency of and risk factors for medication errors by pharmacists during order verification in a…
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psnet.ahrq.gov/issue/nurses-perspectives-medication-errors-and-prevention-strategies-residential-aged-care
July 13, 2010 - Study
Nurses' perspectives on medication errors and prevention strategies in residential aged care facilities through a national survey.
Citation Text:
Kuppadakkath SC, Bhowmik J, Olasoji M, et al. Nurses' perspectives on medication errors and prevention strategies in residential aged ca…
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psnet.ahrq.gov/issue/predictors-adverse-events-and-medical-errors-among-adult-inpatients-psychiatric-units-acute
November 06, 2019 - Study
Predictors of adverse events and medical errors among adult inpatients of psychiatric units of acute care general hospitals.
Citation Text:
Vermeulen JM, Doedens P, Cullen SW, et al. Predictors of Adverse Events and Medical Errors Among Adult Inpatients of Psychiatric Units of Acut…
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psnet.ahrq.gov/issue/cracking-code-quality-interrelationships-culture-nurse-demographics-advocacy-and-patient
December 01, 2011 - Study
Cracking the code for quality: the interrelationships of culture, nurse demographics, advocacy, and patient outcomes.
Citation Text:
DiCuccio MH, Colbert AM, Triolo PK, et al. Cracking the Code for Quality. J Nurs Admin. 2020;50(3):152-158. doi:10.1097/nna.0000000000000859.
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psnet.ahrq.gov/issue/introduction-mobile-adverse-event-reporting-system-associated-participation-adverse-event
July 03, 2016 - Study
Introduction of a mobile adverse event reporting system is associated with participation in adverse event reporting.
Citation Text:
Rubin DS, Pesyna C, Jakubczyk S, et al. Introduction of a Mobile Adverse Event Reporting System Is Associated With Participation in Adverse Event Repo…
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psnet.ahrq.gov/issue/inappropriate-preinjury-warfarin-use-trauma-patients-call-safety-initiative
August 04, 2021 - Study
Inappropriate preinjury warfarin use in trauma patients: a call for a safety initiative.
Citation Text:
Hon HH, Elmously A, Stehly CD, et al. Inappropriate preinjury warfarin use in trauma patients: A call for a safety initiative. J Postgrad Med. 2016;62(2):73-9. doi:10.4103/0022-3…
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psnet.ahrq.gov/issue/learning-non-routine-events-and-teamwork-intensive-care-units-challenges-and-opportunities
September 11, 2019 - Commentary
Learning from non-routine events and teamwork in intensive care units: challenges and opportunities.
Citation Text:
Gong Y, Chen Y. Learning from non-routine events and teamwork in intensive care units: challenges and opportunities. Stud Health Technol Inform. 2024;310:324-328…
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www.ahrq.gov/policymakers/chipra/demoeval/demostates/co.html
March 01, 2019 - State at a Glance: Colorado
Learn more about the CHIPRA quality demonstration projects being implemented in Colorado.
Colorado is featured in the following reports from the National Evaluation:
Evaluation Highlight No . 3: How are CHIPRA Quality Demonstration States working to improve adolescent health?
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psnet.ahrq.gov/issue/impact-health-information-technology-interventions-improve-medication-laboratory-monitoring
August 11, 2010 - Review
Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review.
Citation Text:
Fischer SH, Tjia J, Field T. Impact of health information technology interventions to improve medication laboratory moni…
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psnet.ahrq.gov/issue/patient-perspectives-delays-diagnosis-and-treatment-cancer-qualitative-analysis-free-text
March 08, 2023 - Study
Patient perspectives on delays in diagnosis and treatment of cancer: a qualitative analysis of free-text data.
Citation Text:
Parsonage RK, Hiscock J, Law R-J, et al. Patient perspectives on delays in diagnosis and treatment of cancer: a qualitative analysis of free-text data. Br J…
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www.ahrq.gov/policymakers/chipra/demoeval/demostates/nm.html
March 01, 2019 - State at a Glance: New Mexico
Learn more about the CHIPRA quality demonstration projects being implemented in New Mexico.
New Mexico is featured in the following reports from the National Evaluation:
Evaluation Highlight No. 3: How are CHIPRA Quality Demonstration States working to improve adolescent hea…
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psnet.ahrq.gov/issue/debunking-myth-majority-medical-errors-are-attributed-communication
February 14, 2024 - Journal Article
Debunking the myth that the majority of medical errors are attributed to communication.
Citation Text:
Clapper TC, Ching K. Debunking the myth that the majority of medical errors are attributed to communication. Med Educ. 2020;54(1):74-81. doi:10.1111/medu.13821.
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psnet.ahrq.gov/issue/missed-opportunities-initiate-endoscopic-evaluation-colorectal-cancer-diagnosis
February 15, 2011 - Study
Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis.
Citation Text:
Singh H, Daci K, Petersen L, et al. Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. Am J Gastroenterol. 2009;104(10):2543-2554. doi:10.103…
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psnet.ahrq.gov/issue/are-online-patient-reviews-associated-health-care-outcomes-systematic-review-literature
September 16, 2020 - Review
Are online patient reviews associated with health care outcomes? A systematic review of the literature.
Citation Text:
Placona AM, Rathert C. Are online patient reviews associated with health care outcomes? A systematic review of the literature. Med Care Res Rev. 2022;79(1):3-16. …
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psnet.ahrq.gov/issue/association-between-sepsis-and-potential-medical-injury-among-hospitalized-patients
July 15, 2014 - Study
The association between sepsis and potential medical injury among hospitalized patients.
Citation Text:
Liu V, Turk BJ, Rizk NW, et al. The association between sepsis and potential medical injury among hospitalized patients. Chest. 2012;142(3):606-613. doi:10.1378/chest.11-2556. …
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psnet.ahrq.gov/issue/medication-error-prevention-survey-five-years-results
March 26, 2015 - Study
A medication error prevention survey: five years of results.
Citation Text:
Cusano FL, Chambers C, Summach L. A medication error prevention survey: five years of results. J Oncol Pharm Pract. 2009;15(2):87-93. doi:10.1177/1078155208099284.
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psnet.ahrq.gov/issue/establishing-ambulatory-medicine-quality-and-safety-oversight-structure-leveraging-fractal
July 01, 2017 - Commentary
Establishing an ambulatory medicine quality and safety oversight structure: leveraging the fractal model.
Citation Text:
Kravet SJ, Bailey J, Demski R, et al. Establishing an Ambulatory Medicine Quality and Safety Oversight Structure: Leveraging the Fractal Model. Acad Med. 20…