-
psnet.ahrq.gov/node/46729/psn-pdf
January 17, 2018 - Diagnostic error in pediatric cancer.
January 17, 2018
Carberry AR, Hanson K, Flannery A, et al. Diagnostic Error in Pediatric Cancer. Clin Pediatr (Phila).
2017;57*1((1):11-18. doi:10.1177/0009922816687325.
https://psnet.ahrq.gov/issue/diagnostic-error-pediatric-cancer
Missed or delayed cancer diagnoses can lead …
-
psnet.ahrq.gov/node/849139/psn-pdf
May 17, 2023 - How the opioid backlash went wrong.
May 17, 2023
Freedman DH. Newsweek Magazine. May 12, 2023.
https://psnet.ahrq.gov/issue/how-opioid-backlash-went-wrong
The unintended consequences of reductions in access to prescription opioids can result in poor addiction
care and ineffective pain management. This articl…
-
www.ahrq.gov/evidencenow/tools/ground-rules.html
November 01, 2018 - Developing Ground Rules for Primary Care Team Communication
Resource: Ground Rules for Team Communication (PDF, 268 KB, 7 pages)
Agreeing about how and when to communicate with each other can ensure productive, respectful meetings, and high-functioning teams during patient care. This resource can be used to…
-
www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-14.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 3.14. Project Team Composition—Hip and Knee Replacement Costs
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview He…
-
psnet.ahrq.gov/node/840477/psn-pdf
November 30, 2022 - Common and consequential fractures that should not be
missed in children.
November 30, 2022
Tougas C, Brimmo O. Common and consequential fractures that should not be missed in children. Pediatr
Ann. 2022;51(9):e357-e363. doi:10.3928/19382359-20220706-05.
https://psnet.ahrq.gov/issue/common-and-consequential-fractu…
-
www.ahrq.gov/nursing-home/resources/post-traumatic-stress-symptoms.html
September 01, 2021 - Post-Traumatic Stress Symptoms in Healthcare Workers Dealing with the COVID-19 Pandemic: A Systematic Review
Resource: Post-Traumatic Stress Symptoms in Healthcare Workers Dealing with the COVID-19 Pandemic: A Systematic Review
Prevention of post-traumatic stress symptoms (PTSS) in healthcare workers (HCWs)…
-
psnet.ahrq.gov/node/47794/psn-pdf
April 03, 2019 - Perchance to think.
April 3, 2019
Ofri D. Perchance to Think. New Engl J Med. 2019;380(13):1197-1199. doi:10.1056/NEJMp1814019.
https://psnet.ahrq.gov/issue/perchance-think
Production pressure, fatigue, and distraction can diminish effective decision-making. This commentary
offers insights from an ambulatory care …
-
psnet.ahrq.gov/node/47938/psn-pdf
May 01, 2019 - Drug diversion and impaired health care workers.
May 1, 2019
Quick Safety. April 15, 2019;(48):1-3.
https://psnet.ahrq.gov/issue/drug-diversion-and-impaired-health-care-workers
Fatigue, emotional stress, and illness can affect decision-making and lead to misuse of medications. This
newsletter article describes the…
-
psnet.ahrq.gov/node/837710/psn-pdf
July 20, 2022 - Independent Neurology Inquiry.
July 20, 2022
Lockhart B, Mascie-Taylor H. Crown Copyright: London, England; June 2022. ISBN
9781912313631.
https://psnet.ahrq.gov/issue/independent-neurology-inquiry
Misdiagnosis of neurological conditions, such as stroke, can lead to delays in treatment and patient
morbidity…
-
psnet.ahrq.gov/node/46800/psn-pdf
May 16, 2018 - Ireland investigates cervical cancer screening scandal.
May 16, 2018
O'Loughlin E. New York Times. April 30, 2018.
https://psnet.ahrq.gov/issue/ireland-investigates-cervical-cancer-screening-scandal
Large-scale adverse events should lead to system examination and improvement. This newspaper article
reports on misr…
-
psnet.ahrq.gov/node/42857/psn-pdf
January 15, 2014 - The landscape of inappropriate laboratory testing: a 15-
year meta-analysis.
January 15, 2014
Zhi M, Ding EL, Theisen-Toupal J, et al. The landscape of inappropriate laboratory testing: a 15-year meta-
analysis. PLoS One. 2013;8(11):e78962. doi:10.1371/journal.pone.0078962.
https://psnet.ahrq.gov/issue/landscape-i…
-
psnet.ahrq.gov/node/40747/psn-pdf
September 07, 2011 - Misdiagnosis: analysis based on case record review with
proposals aimed to improve diagnostic processes.
September 7, 2011
Neale G, Hogan H, Sevdalis N. Misdiagnosis: analysis based on case record review with proposals aimed
to improve diagnostic processes. Clin Med (Lond). 2011;11(4):317-321.
https://psnet.ahrq.g…
-
psnet.ahrq.gov/node/39486/psn-pdf
May 05, 2010 - Understanding handling of drug safety alerts: a
simulation study.
May 5, 2010
van der Sijs H, van Gelder T, Vulto A, et al. Understanding handling of drug safety alerts: a simulation
study. Int J Med Inform. 2010;79(5). doi:10.1016/j.ijmedinf.2010.01.008.
https://psnet.ahrq.gov/issue/understanding-handling-drug-sa…
-
www.ahrq.gov/hai/clabsi-tools/about.html
March 01, 2018 - About the Toolkit Development
Background
This toolkit was developed based on the experiences of more than 1,000 ICUs that participated in the On the CUSP: Stop BSI project. These ICUs reduced CLABSIs by 41 percent using the CUSP method and resources included in this toolkit.
Project partners
Health Rese…
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/guide.html
December 01, 2017 - It also asks which staff members are invited, who leads the meeting, and how often it occurs.
-
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/projects/state/how-to-guide/how-to-guide.pdf
August 01, 2024 - equally shared
• Highly developed communication
systems
19
Lead Organization
The organization that leads … included the two project principal
investigators (PIs), representatives from member partners, and the leads … accomplish their key activities, it can be helpful to also hold regular meetings of the
working group leads
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/medical-test-reviews-choosing-outcomes.ppt
June 01, 2012 - Society as a whole may experience some outcomes, as when a test of an individual leads to a public health … The authors might also have explicitly included an outcome that examines whether the screening leads … to receipt of antibiotic treatment, essentially whether screening leads to change in clinical management
-
effectivehealthcare.ahrq.gov/sites/default/files/medical-test-reviews-choosing-outcomes.ppt
June 01, 2012 - Society as a whole may experience some outcomes, as when a test of an individual leads to a public health … The authors might also have explicitly included an outcome that examines whether the screening leads … to receipt of antibiotic treatment, essentially whether screening leads to change in clinical management
-
www.ahrq.gov/sites/default/files/2025-02/holl-report.pdf
January 01, 2025 - • Corrected by improving the receiving skills of practitioners
• Creation of shared understanding leads … Lack of standard process leads to delays in transfer or transfer to the wrong level of care.
12
-
psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - RW : I guess that leads to a concern: if you think about what health systems have done to address other