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psnet.ahrq.gov/issue/morbidity-and-mortality-conferences-narrative-review-strategies-prioritize-quality
January 11, 2023 - Review
Morbidity and mortality conferences: a narrative review of strategies to prioritize quality improvement.
Citation Text:
Giesbrecht V, Au S. Morbidity and Mortality Conferences: A Narrative Review of Strategies to Prioritize Quality Improvement. Jt Comm J Qual Patient Saf. 2016;42(…
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psnet.ahrq.gov/issue/ashp-national-survey-pharmacy-practice-hospital-settings-prescribing-and-transcribing-2007
September 30, 2020 - Study
ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2007.
Citation Text:
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing--2007. Am J Health Syst Pharm…
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psnet.ahrq.gov/issue/ashp-national-survey-pharmacy-practice-hospital-settings-prescribing-and-transcribing-2013
September 30, 2020 - Study
ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2013.
Citation Text:
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing-2013. Am J Health Syst Pharm. 2…
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psnet.ahrq.gov/issue/impact-burnout-paediatric-nurses-attitudes-about-patient-safety-acute-hospital-setting
June 05, 2019 - Review
The impact of burnout on paediatric nurses' attitudes about patient safety in the acute hospital setting: a systematic review.
Citation Text:
Flynn C, Watson C, Patton D, et al. The impact of burnout on paediatric nurses' attitudes about patient safety in the acute hospital setti…
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psnet.ahrq.gov/issue/reasons-repeat-rapid-response-team-calls-and-associations-hospital-mortality
March 03, 2020 - Study
Reasons for repeat rapid response team calls, and associations with in-hospital mortality.
Citation Text:
Chalwin R, Giles L, Salter A, et al. Reasons for Repeat Rapid Response Team Calls, and Associations with In-Hospital Mortality. Jt Comm J Qual Patient Saf. 2019;45(4):268-275. …
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psnet.ahrq.gov/issue/patient-engagement-surgical-site-infection-prevention-expert-panel-perspective
June 03, 2020 - Review
Patient engagement with surgical site infection prevention: an expert panel perspective.
Citation Text:
Tartari E, Weterings V, Gastmeier P, et al. Patient engagement with surgical site infection prevention: an expert panel perspective. Antimicrob Resist Infect Control. 2017;6:45.…
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psnet.ahrq.gov/issue/laboratory-testing-general-practice-patient-safety-blind-spot
July 29, 2015 - Commentary
Laboratory testing in general practice: a patient safety blind spot.
Citation Text:
Elder NC. Laboratory testing in general practice: a patient safety blind spot. BMJ Qual Saf. 2015;24(11):667-70. doi:10.1136/bmjqs-2015-004644.
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psnet.ahrq.gov/issue/making-move-using-simulation-identify-latent-safety-threats-care-injured-patients-new
December 30, 2014 - Commentary
Making a move: using simulation to identify latent safety threats before the care of injured patients in a new physical space.
Citation Text:
Kotagal M, Falcone RA, Daugherty M, et al. Making a move: Using simulation to identify latent safety threats before the care of injured…
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psnet.ahrq.gov/issue/updating-eindhoven-clarifying-features-patient-safety-near-miss
March 13, 2024 - Study
Updating Eindhoven: clarifying the features of a patient safety near miss.
Citation Text:
Woodier N, Burnett C, Sampson P, et al. Updating Eindhoven: clarifying the features of a patient safety near miss. J Patient Saf Risk Manag. 2024;29(4):195-201. doi:10.1177/25160435241247096. …
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psnet.ahrq.gov/issue/knowledge-attitudes-and-expectations-medical-staff-toward-medical-error-management-policies
December 23, 2020 - Study
Knowledge, attitudes, and expectations of medical staff toward medical error management policies in humanitarian medicine: a qualitative study.
Citation Text:
Biquet J-M, Schopper D, Sprumont D, et al. Knowledge, attitudes, and Expectations of Medical Staff Toward Medical Error Ma…
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psnet.ahrq.gov/issue/educational-targets-reduce-medication-errors-general-surgery-residents
October 19, 2022 - Study
Educational targets to reduce medication errors by general surgery residents.
Citation Text:
Chaitoff A, Strong AT, Bauer SR, et al. Educational Targets to Reduce Medication Errors by General Surgery Residents. J Surg Educ. 2019;76(6):1612-1621. doi:10.1016/j.jsurg.2019.04.009.
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psnet.ahrq.gov/issue/organizational-response-known-medical-errors-does-peer-review-protection-impede-improvement
April 24, 2018 - Commentary
Organizational response to known medical errors: does peer review protection impede improvement?
Citation Text:
Wenner WJ, Choi SW. Organizational Response to Known Medical Errors: Does Peer Review Protection Impede Improvement? Am J Med Qual. 2018;33(5):552-553. doi:10.1177/1…
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psnet.ahrq.gov/issue/better-medical-office-safety-culture-not-associated-better-scores-quality-measures
April 12, 2011 - Study
Better medical office safety culture is not associated with better scores on quality measures.
Citation Text:
Hagopian B, Singer ME, Curry-Smith AC, et al. Better medical office safety culture is not associated with better scores on quality measures. J Patient Saf. 2012;8(1):15-2…
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psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis
January 06, 2017 - Study
Process of care failures in breast cancer diagnosis.
Citation Text:
Weingart SN, Saadeh MG, Simchowitz B, et al. Process of care failures in breast cancer diagnosis. J Gen Intern Med. 2009;24(6):702-709. doi:10.1007/s11606-009-0982-0.
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psnet.ahrq.gov/issue/us-national-trends-pediatric-deaths-prescription-and-illicit-opioids-1999-2016
January 23, 2017 - Study
US national trends in pediatric deaths from prescription and illicit opioids, 1999–2016.
Citation Text:
Gaither JR, Shabanova V, Leventhal JM. US National Trends in Pediatric Deaths From Prescription and Illicit Opioids, 1999-2016. JAMA Netw Open. 2018;1(8):e186558. doi:10.1001/jam…
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psnet.ahrq.gov/issue/improving-our-understanding-multi-tasking-healthcare-drawing-together-cognitive-psychology
July 19, 2018 - Review
Improving our understanding of multi-tasking in healthcare: drawing together the cognitive psychology and healthcare literature.
Citation Text:
Douglas HE, Raban MZ, Walter SR, et al. Improving our understanding of multi-tasking in healthcare: Drawing together the cognitive psycho…
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www.ahrq.gov/news/newsroom/case-studies/coe1304.html
April 01, 2013 - Maryland Guides Prescribers on Use of Atypical Antipsychotic Medications
Search All Impact Case Studies
April 2013
The Maryland Department of Health and Mental Hygiene used materials created by AHRQ's Effective Health Care Program to help set up a new program for appropriate use of antipsychotic medications…
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psnet.ahrq.gov/issue/institution-just-culture-physician-peer-review-academic-medical-center
October 20, 2021 - Study
Institution of just culture physician peer review in an academic medical center.
Citation Text:
Volkar JK, Phrampus P, English D, et al. Institution of just culture physician peer review in an academic medical center. J Patient Saf. 2021;17(7):e689-e693. doi:10.1097/pts.00000000000…
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psnet.ahrq.gov/issue/identifying-hot-spots-harm-and-blind-spots-across-care-pathway-patient-complaints-about
May 04, 2022 - Study
Identifying hot spots for harm and blind spots across the care pathway from patient complaints about general practice.
Citation Text:
O’Dowd E, Lydon S, Lambe KA, et al. Identifying hot spots for harm and blind spots across the care pathway from patient complaints about general pra…
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psnet.ahrq.gov/issue/long-term-impacts-faced-patients-and-families-after-harmful-healthcare-events
December 01, 2021 - Study
Long-term impacts faced by patients and families after harmful healthcare events.
Citation Text:
Ottosen MJ, Sedlock E, Aigbe AO, et al. Long-term impacts faced by patients and families after harmful healthcare events. J Patient Saf. 2021;17(8):e1145-e1151. doi:10.1097/pts.00000000…