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psnet.ahrq.gov/issue/fda-advise-err-reported-medication-errors-veklury-remdesivir-emergency-use-authorization
July 01, 2020 - Newspaper/Magazine Article
FDA Advise-ERR: reported medication errors with Veklury (remdesivir) emergency use authorization.
Citation Text:
FDA Advise-ERR: reported medication errors with Veklury (remdesivir) emergency use authorization. ISMP Medication Safety Alert! Acute care edition.&…
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psnet.ahrq.gov/issue/medication-errors-involving-intravenous-administration-route-characteristics-voluntarily
January 31, 2018 - Review
Medication errors involving the intravenous administration route: characteristics of voluntarily reported medication errors.
Citation Text:
Wolf ZR. Medication Errors Involving the Intravenous Administration Route: Characteristics of Voluntarily Reported Medication Errors. J Infus…
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psnet.ahrq.gov/issue/only-1-5-people-opioid-addiction-get-medications-treat-it-study-finds
October 21, 2020 - Newspaper/Magazine Article
Only 1 in 5 people with opioid addiction get the medications to treat it, study finds.
Citation Text:
Only 1 in 5 people with opioid addiction get the medications to treat it, study finds. Mann B. Health Shots. National Public Radio. August 7, 2023.
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/nasa-task-load-index
January 01, 2023 - NASA Task Load Index
Acronym
NASA TLX
Description
The NASA task load index (NASA TLX) is a tool for measuring and conducting a subjective mental workload (MWL) assessment. It allows you to determine the MWL of a participant while they are performing a task. It rates performance across six dime…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/recruitment-flyer-va.pdf
June 02, 2025 - RecruitmentFlyer_FAQs_VA
Frequently Asked Questions
1. Why should my practice participate in the Heart of Virginia Healthcare (HVH) initiative?
Your practice will receive personalized coaching on optimizing your practice model and culture; helping you
improve cardiovascular care for your patients. Improving func…
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psnet.ahrq.gov/issue/improving-quality-and-safety-patient-care-cardiac-anesthesia
September 26, 2012 - Review
Improving the quality and safety of patient care in cardiac anesthesia.
Citation Text:
Merry A, Weller J, Mitchell SJ. Improving the quality and safety of patient care in cardiac anesthesia. J Cardiothorac Vasc Anesth. 2014;28(5):1341-51. doi:10.1053/j.jvca.2014.02.018.
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psnet.ahrq.gov/issue/guideline-implementation-team-communication
October 15, 2014 - Commentary
Guideline implementation: team communication.
Citation Text:
Link T. Guideline Implementation: Team Communication: 1.8 www.aornjournal.org/content/cme. AORN J. 2018;108(2):165-177. doi:10.1002/aorn.12300.
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Format:
DOI Google Scholar PubMed BibTeX End…
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psnet.ahrq.gov/issue/coaching-improve-quality-communication-during-briefings-and-debriefings
March 02, 2022 - Study
Coaching to improve the quality of communication during briefings and debriefings.
Citation Text:
Kleiner C, Link T, Maynard T, et al. Coaching to improve the quality of communication during briefings and debriefings. AORN J. 2014;100(4):358-68. doi:10.1016/j.aorn.2014.03.012.
Co…
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psnet.ahrq.gov/issue/placing-diagnosis-errors-policy-agenda
October 31, 2014 - Book/Report
Placing Diagnosis Errors on the Policy Agenda.
Citation Text:
Placing Diagnosis Errors on the Policy Agenda. Berenson RA, Upadhyay D, Kaye DR. Washington, DC: Urban Institute. Princeton, NJ: Robert Wood Johnson Foundation; 2014.
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psnet.ahrq.gov/issue/any-new-process-poses-risk-errors-learning-4-months-coronavirus-disease-2019-covid-19
June 10, 2018 - Newspaper/Magazine Article
Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations.
Citation Text:
Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations. ISMP Medicat…
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psnet.ahrq.gov/issue/making-doctors-better
June 15, 2016 - Commentary
Making doctors better.
Citation Text:
Gerada C, Chatfield C, Rimmer A, et al. Making doctors better. BMJ. 2018;363:k4147. doi:10.1136/bmj.k4147.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/issue/legal-and-policy-interventions-improve-patient-safety
February 17, 2011 - Review
Legal and policy interventions to improve patient safety.
Citation Text:
Kachalia A, Mello MM, Nallamothu BK, et al. Legal and Policy Interventions to Improve Patient Safety. Circulation. 2016;133(7):661-71. doi:10.1161/CIRCULATIONAHA.115.015880.
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psnet.ahrq.gov/issue/diagnostic-errors-inserted-tubes-lines-and-catheters-children
September 11, 2019 - Study
Diagnostic errors with inserted tubes, lines and catheters in children.
Citation Text:
Fuentealba I, Taylor GA. Diagnostic errors with inserted tubes, lines and catheters in children. Pediatr Radiol. 2012;42(11):1305-15. doi:10.1007/s00247-012-2462-7.
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psnet.ahrq.gov/issue/sleep-and-alertness-duty-hour-flexibility-trial-internal-medicine
March 13, 2019 - Study
Emerging Classic
Sleep and alertness in a duty-hour flexibility trial in internal medicine.
Citation Text:
Sleep and alertness in a duty-hour flexibility trial in internal medicine. Basner M, Asch DA, Shea JA, et al; iCOMPARE Research Group. N Engl J Med. …
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psnet.ahrq.gov/issue/skating-thin-ice-consultant-surgeons-contemporary-experience-adverse-surgical-events
April 17, 2024 - Study
'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events.
Citation Text:
Skevington SM, Langdon JE, Giddins G. ‘Skating on thin ice?’ Consultant surgeon's contemporary experience of adverse surgical events. Psychol Health Med. 2011;17(1). doi…
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psnet.ahrq.gov/issue/using-simulation-improve-patient-safety-dawn-new-era
October 29, 2017 - Commentary
Using simulation to improve patient safety: dawn of a new era.
Citation Text:
Cheng A, Grant V, Auerbach M. Using simulation to improve patient safety: dawn of a new era. JAMA Pediatr. 2015;169(5):419-20. doi:10.1001/jamapediatrics.2014.3817.
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psnet.ahrq.gov/issue/its-not-all-about-me-motivating-hand-hygiene-among-health-care-professionals-focusing
May 29, 2019 - Study
It's not all about me: motivating hand hygiene among health care professionals by focusing on patients.
Citation Text:
Grant AM, Hofmann DA. It's not all about me: motivating hand hygiene among health care professionals by focusing on patients. Psychol Sci. 2011;22(12):1494-9. do…
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psnet.ahrq.gov/issue/leadership-challenge-staff-nurse-perceptions-after-organizational-teamstepps-initiative
May 11, 2016 - Study
A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative.
Citation Text:
Castner J, Foltz-Ramos K, Schwartz DG, et al. A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative. J Nurs Adm. 2012;42(10):467-47…
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psnet.ahrq.gov/issue/pushing-profession-how-news-media-turned-patient-safety-priority
September 02, 2018 - Review
Classic
Pushing the profession: how the news media turned patient safety into a priority.
Citation Text:
Millenson ML. Pushing the profession: how the news media turned patient safety into a priority. Qual Saf Health Care. 2002;11(1):57-63.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/131-what-are-the-4-es-one-pager.docx
May 24, 2024 - The aim is to Engage hearts and minds and thus, change attitudes and behaviors.1-6
Raise awareness of the problem, communicate benefits of the solution, and lay out the goals for the intervention.
· Use unit data, published literature, and national benchmarks. Storytelling is an underrated tool.
Engagement is not a on…