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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46708/psn-pdf
    February 08, 2023 - FDA/ISMP Safe Medication Management Fellowship Program. February 8, 2023 Food and Drug Administration, Institute for Safe Medication Practices. https://psnet.ahrq.gov/issue/fdaismp-safe-medication-management-fellowship-program This fellowship program provides clinicians with learning opportunities at the Institute…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47406/psn-pdf
    October 31, 2018 - Systems Approach in Healthcare. October 31, 2018 Dean J, Clarkson J, eds. Future Hosp J. 2018;5:145-187. https://psnet.ahrq.gov/issue/systems-approach-healthcare The systems approach has long been heralded as a key element to safe patient care. Articles in this special issue explore techniques to engage clinicians…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44613/psn-pdf
    October 28, 2015 - Getting rid of "never events" in hospitals. October 28, 2015 Morgenthaler T; Harper CM. https://psnet.ahrq.gov/issue/getting-rid-never-events-hospitals Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them. This commentary discusses how the Mayo…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849337/psn-pdf
    May 24, 2023 - Actions to renew focus on safety culture. May 24, 2023 Salvon-Harman J. Healthcare Executive. 2023;39(3):48-49. https://psnet.ahrq.gov/issue/actions-renew-focus-safety-culture A strong safety work environment is core to reliable care delivery and staff wellbeing. This article discusses how leadership should listen…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866322/psn-pdf
    July 17, 2024 - UCSF Coordinating Center for Diagnostic Excellence (CoDEx). July 17, 2024 University of California, San Francisco. https://psnet.ahrq.gov/issue/ucsf-coordinating-center-diagnostic-excellence-codex Diagnostic excellence is an emergent field of study that aligns with diagnostic error reduction efforts. This center …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35452/psn-pdf
    January 05, 2017 - Deploying Six Sigma in a health care system as a work in progress. January 5, 2017 Christianson JB, Warrick LH, Howard R, et al. Deploying Six Sigma in a health care system as a work in progress. Jt Comm J Qual Patient Saf. 2005;31(11):603-13. https://psnet.ahrq.gov/issue/deploying-six-sigma-health-care-system-wor…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50719/psn-pdf
    December 04, 2019 - A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! December 4, 2019 ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019 https://psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here The reporting and analysis of incidents i…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50667/psn-pdf
    November 13, 2019 - Proactive prevention of maternal death from maternal hemorrhage. November 13, 2019 Quick Safety. October 29, 2019;(51):1-3. https://psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage The reduction of postpartum hemorrhage and the overall improvement of maternal safety is a patient safety …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44109/psn-pdf
    November 06, 2015 - Safer Clinical Systems. November 6, 2015 London, UK: Health Foundation. https://psnet.ahrq.gov/issue/safer-clinical-systems This Web site highlights the work of a United Kingdom initiative launched in 2008 to apply safety improvement tactics from high-risk industries to care services. The program engages teams to …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40499/psn-pdf
    June 01, 2011 - Patient-assisted incident reporting: including the patient in patient safety. June 1, 2011 Millman A, Pronovost P, Makary MA, et al. Patient-assisted incident reporting: including the patient in patient safety. J Patient Saf. 2011;7(2):106-8. doi:10.1097/PTS.0b013e31821b3c5f. https://psnet.ahrq.gov/issue/patient-a…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41231/psn-pdf
    March 21, 2012 - Junior doctors' reflections on patient safety. March 21, 2012 Ahmed M, Arora S, Carley S, et al. Junior doctors' reflections on patient safety. Postgrad Med J. 2012;88(1037):125-9. doi:10.1136/postgradmedj-2011-130301. https://psnet.ahrq.gov/issue/junior-doctors-reflections-patient-safety This study used written p…

  12. Imputing missing covariates in time-to-event analysis within distributed research networks: A simulation study. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/improving-missing-data-analysis-distributed-research-networks/citation/imputing
    January 01, 2023 - Imputing missing covariates in time-to-event analysis within distributed research networks: A simulation study. Citation Li D, Wong J, Li X, Toh S, Wang R. Imputing missing covariates in time-to-event analysis within distributed research networks: A simulation study. Pharmacoepidemiol Drug Saf. 2023 …

  13. A factored generalized additive model for clinical decision support in the operating room. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/anesthesiology-control-tower-feedback-alerts-supplement-treatment-actfast/citation/factored
    January 01, 2023 - A factored generalized additive model for clinical decision support in the operating room. Citation Cui Z, Fritz BA, King CR, Avidan MS, Chen Y. A factored generalized additive model for clinical decision support in the operating room. AMIA Annu Symp Proc. 2020 Mar 4;2019:343-52. PMID 32308827. …

  14. Accelerating Change and Transformation in Organizations and Networks (ACTION) IV | Digital Healthcare Research

    digital.ahrq.gov/funding-mechanism/accelerating-change-and-transformation-organizations-and-networks-action-iv
    January 01, 2023 - Accelerating Change and Transformation in Organizations and Networks (ACTION) IV Clinical Decision Support Innovation Collaborative (CDSiC) Description The Clinical Decision Support Innovation Collaborative (CDSiC) created a learning community of patients, providers, policymak…

  15. Responding to health information technology reported safety events: Insights from patient safety event reports. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/developing-evidence-based-user-centered-design-and-implementation-guidelines/citation/responding
    January 01, 2023 - Responding to health information technology reported safety events: Insights from patient safety event reports. Citation Adams K.T., Kim T.C., Fong A., Howe J.L., Kellogg K.M., Ratwani R.M. (2019) Responding to health IT reported safety events: Insights from patient safety event reports. Journal of Pa…

  16. Identifying health information technology related safety event reports from patient safety event report databases. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/developing-evidence-based-user-centered-design-and-implementation-guidelines/citation/identifying
    January 01, 2023 - Identifying health information technology related safety event reports from patient safety event report databases. Citation Fong A, Adams KT, Gaunt MJ, et al. Identifying health information technology related safety event reports from patient safety event report databases. J Biomed Inform 2018 Oct;86:…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42869/psn-pdf
    January 28, 2017 - Exploring Alternatives To Malpractice Litigation. January 28, 2017 Improved safety, eliminating errors top policy agenda. Health Aff (Millwood). 2014;33(1):6-66. https://psnet.ahrq.gov/issue/exploring-alternatives-malpractice-litigation Articles in this special issue cover findings from a federally-funded initiativ…

  18. Parent-reported outcomes of a shared decision-making portal in asthma: a practice-based RCT. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/national-center-pediatric-practice-based-research-and-learning/citation/parent
    January 01, 2023 - Parent-reported outcomes of a shared decision-making portal in asthma: a practice-based RCT. Citation Fiks AG, Mayne SL, Karavite DJ, et al. Parent-reported outcomes of a shared decision-making portal in asthma: a practice-based RCT. Pediatrics 2015;135(4):e965–73. PMID: 25755233. Link https:/…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35358/psn-pdf
    March 02, 2011 - Systematic review: effects of resident work hours on patient safety. March 2, 2011 Fletcher KE, Davis SQ, Underwood W, et al. Systematic review: effects of resident work hours on patient safety. Ann Intern Med. 2004;141(11):851-857. https://psnet.ahrq.gov/issue/systematic-review-effects-resident-work-hours-patient…

  20. Implementation Guide for Enhancing Care Coordination for Cardiac Rehabilitation (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/care-coordination-implementation-guide.pdf
    March 01, 2023 - up with patients who were referred but failed to enroll -- or who enrolled but never attended – to learn … The CDC defines SDOH as “the conditions in the environments where people are born, live, learn, work
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