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4561. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
      January 01, 2004 - Quantitative and Qualitative Analysis of Medication Errors: The New York Experience 131 Quantitative and Qualitative Analysis of Medication Errors: The New York Experience Elizabeth Duthie, Barbara Favreau, Angelo Ruperto, Janet Mannion, Ellen Flink, Ruth Leslie Abstract Objectives: In June 2000, the New Yo…

4562. Organizational Climate, Stress, and Error in Primary Care: The MEMO Study (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Linzer.pdf
      January 01, 2002 - Organizational Climate, Stress, and Error in Primary Care: The MEMO Study 65 Organizational Climate, Stress, and Error in Primary Care: The MEMO Study* Mark Linzer, Linda Baier Manwell, Marlon Mundt, Eric Williams, Ann Maguire, Julia McMurray, Mary Beth Plane* Abstract Background: The impact of organizatio…

4563. An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
      January 01, 2003 - An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors 39 An Analysis of Nurses’ Cognitive Work: A New Perspective for Understanding Medical Errors Patricia Potter, Laurie Wolf, Stuart Boxerman, Deborah Grayson, Jennifer Sledge, Clay Dunagan, Bradley Evanoff Abstract He…

4564. Evaluating and Predicting Patient Safety for Medical Devices with Integral Information Technology (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Zhang.pdf
      January 01, 2004 - Evaluating and Predicting Patient Safety for Medical Devices with Integral Information Technology 323 Evaluating and Predicting Patient Safety for Medical Devices with Integral Information Technology Jiajie Zhang, Vimla L. Patel, Todd R. Johnson, Philip Chung, James P. Turley Abstract Human errors in med…

4565. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Hunt.pdf
      July 01, 2004 - Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency 105 Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency David R. Hunt, Nancy Verzier, Susan L. Abend, Courtney Lyder, Lisa J. Jaser, Nancy Safer, Paul Davern Abstract The Medicar…

4566. Proactive Postmarketing Surveillance: Overview and Lessons Learned from Medication Safety Research in the Veterans Health Administration (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell-R_106.pdf
      April 14, 2008 - Proactive Postmarketing Surveillance: Overview and Lessons Learned from Medication Safety Research in the Veterans Health Administration Proactive Postmarketing Surveillance: Overview and Lessons Learned from Medication Safety Research in the Veterans Health Administration Robert R. Campbell, JD, MPH, PhD; An…

4567. Institutional Review Board Approval of Practice-based Research Network Patient Safety Studies (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Graham.pdf
      April 14, 2004 - Institutional Review Board Approval of Practice-based Research Network Patient Safety Studies 453 Institutional Review Board Approval of Practice-based Research Network Patient Safety Studies Deborah G. Graham, Wilson Pace, Jennifer Kappus, Sherry Holcomb, James M. Galliher, Christine W. Duclos, Aaron J. B…

4568. On-line Patient Safety Climate Survey: Tool Development and Lessons Learned (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Connelly.pdf
      January 01, 2003 - On-line Patient Safety Climate Survey: Tool Development and Lessons Learned 415 On-line Patient Safety Climate Survey: Tool Development and Lessons Learned Lynne M. Connelly, Judy L. Powers Abstract Objective: A key tenet of patient safety programs is the elimination of the “culture of blame.” The On-line P…

4569. Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/OConnor.pdf
      November 29, 2004 - Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care 369 Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care Patrick J. O’Connor, JoAnn M. Sperl-Hillen, Paul E. Johnson, William A. Rush Abstract Objectives: Diabetes-related medic…

4570. Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Baker_107.pdf
      March 30, 2008 - Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Donald K. Baker, PharmD; James M. Hoffman, PharmD; Gregory A. Hal…

4571. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
      April 02, 2008 - The Nature, Characteristics and Patterns of Perinatal Critical Events Teams The Nature, Characteristics and Patterns of Perinatal Critical Events Teams William Riley, PhD; Helen Hansen, PhD, RN; Ayse P. Gürses, PhD; Stanley Davis, MD; Kristi Miller, RN, MS; Reinhard Priester, JD Abstract The Institute …

4572. The Use of Surgical Simulators to Reduce Errors (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Fried.pdf
      January 01, 2003 - The Use of Surgical Simulators to Reduce Errors 165 The Use of Surgical Simulators to Reduce Errors Marvin P. Fried, Richard Satava, Suzanne Weghorst, Anthony Gallagher, Clarence Sasaki, Douglas Ross, Mika Sinanan, Hernando Cuellar, Jose I. Uribe, Michael Zeltsan, Harman Arora Abstract The training of…

4573. Recruitment and Retention of Primary Care Practices in Quality Improvement Initiatives: A Toolkit (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/recruitment-and-retention-toolkit.pdf
      January 01, 2019 - Recruitment and Retention of Primary Care Practices in Quality Improvement Initiatives: A Toolkit Recruitment and Retention of Primary Care Practices in Quality Improvement Initiatives: A Toolkit Effectively engaging practices in a primary care quality improvement (QI) initiative, including both the initi…

4574. Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_111.pdf
      June 18, 2008 - Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period Ray R. Maddox, PharmD; Harold Oglesby…

4575. Final Progress Report: What About Mom? Using Administrative Data To Develop Measures for Monitoring Healthcare Quality in Pregnancy & Childbirth (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/gregory-report.pdf
      January 01, 2024 - Given that pregnancy is the leading cause of hospital admissions, monitoring safety and quality is imperative

4576. Final Progress Report: Demonstration Project To Refine, Automate and Test a Novel Emergency Department Trigger Tool (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/griffey-report.pdf
      January 01, 2025 - the potential for subjectivity and hindsight bias as to whether omissions represent failures to act leading

4577. AHRQ's Safety Program for Nursing Homes: On-Time Falls Prevention Training (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxreports-ig.pdf
      November 09, 2017 - literature,  Fall elements and scoring from existing instruments, and  Input from an advisory panel of leading

4578. Final Progress Report: Auditory Perception of Drug Names: Neighborhood Effects (pdf file)
      www.ahrq.gov/sites/default/files/2024-03/lambert3-report.pdf
      January 01, 2024 - and 98,000 Americans die each year as the result of medical errors, making such errors the fourth leading

4579. Patient and Family-Centered Care (April 9, 2013) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/patient-family-centered-care-transcript.html
      December 01, 2017 - going to spend too much time on this; this is the four E's model that we have in the Hopkins model for leading

4580. Patient-Family-Centered-Care-Transcript (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/patient-family-centered-care-transcript.doc
      April 09, 2013 - going to spend too much time on this; this is the four E's model that we have in the Hopkins model for leading