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2521. Peterson Regional Medical Center Uses AHRQ's CUSP and Hospital Survey to Advance Patient Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/201419.html
      November 01, 2014 - Peterson Regional Medical Center Uses AHRQ's CUSP and Hospital Survey to Advance Patient Safety Search All Impact Case Studies November 2014 Peterson Regional Medical Center, a 125-bed rural hospital in Kerrville, TX, is using AHRQ's Comprehensive Unit-based Safety Program (CUSP) to eliminate central-line…

2522. The Theory of Distributed Cognition | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses2.html
      August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department The Theory of Distributed Cognition Previous Page Next Page Table of Contents Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Introduction The Theory of Dis…

2523. Case Studies | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/clabsi-hpwpreport/clabsi-hpwp2.html
      August 01, 2015 - High-Performance Work Practices in CLABSI Prevention Interventions Case Studies Previous Page Next Page Table of Contents High-Performance Work Practices in CLABSI Prevention Interventions Case Studies Key Findings Conclusions References Table 1. Case Study Sites Table 2. Summary of Ke…

2524. Leadership Support | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-sustainability-centers-of-excellence5.html
      April 01, 2025 - Four Pillars for Sustainable Centers of Excellence Leadership Support Previous Page Next Page Table of Contents Four Pillars for Sustainable Centers of Excellence Introduction Center of Excellence Operations Alignment Integration Leadership Support Windows of Opportunity Conclusion A…

2525. Exploring the human factors of prescribing errors in paediatric intensive care units. | PSNet
      psnet.ahrq.gov/issue/exploring-human-factors-prescribing-errors-paediatric-intensive-care-units
      March 06, 2024 - Study Emerging Classic Exploring the human factors of prescribing errors in paediatric intensive care units. Citation Text: Sutherland A, Ashcroft DM, Phipps D. Exploring the human factors of prescribing errors in paediatric intensive care units. Arch Dis Child.…

2526. Blood and blood products transfusion errors: what can we do to improve patient safety. | PSNet
      psnet.ahrq.gov/issue/blood-and-blood-products-transfusion-errors-what-can-we-do-improve-patient-safety
      September 23, 2020 - Review Blood and blood products transfusion errors: what can we do to improve patient safety. Citation Text: Brown C, Brown M. Blood and blood products transfusion errors: what can we do to improve patient safety? Br J Nurs. 2023;32(7):326-332. doi:10.12968/bjon.2023.32.7.326. Copy Cit…

2527. Comparing rates of adverse events and medical errors on inpatient psychiatric units at Veterans Health Administration and community-based general hospitals. | PSNet
      psnet.ahrq.gov/issue/comparing-rates-adverse-events-and-medical-errors-inpatient-psychiatric-units-veterans-health
      January 30, 2019 - Study Comparing rates of adverse events and medical errors on inpatient psychiatric units at Veterans Health Administration and community-based general hospitals. Citation Text: Cullen SW, Xie M, Vermeulen JM, et al. Comparing Rates of Adverse Events and Medical Errors on Inpatient Psych…

2528. "Mr Smith's been our problem child today...": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs. | PSNet
      psnet.ahrq.gov/issue/mr-smiths-been-our-problem-child-today-anticipatory-management-communication-amc-va-end-shift
      January 22, 2016 - Study "Mr Smith's been our problem child today...": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs. Citation Text: Bergman AA, Flanagan ME, Ebright PR, et al. "Mr Smith's been our problem child today…": anticipatory management communication (…

2529. Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit. | PSNet
      psnet.ahrq.gov/issue/use-design-thinking-and-human-factors-approach-improve-situation-awareness-pediatric
      January 19, 2022 - Study Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit. Citation Text: Gifford A, Butcher B, Chima RS, et al. Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive c…

2530. A comparative review of patient safety initiatives for national health information technology. | PSNet
      psnet.ahrq.gov/issue/comparative-review-patient-safety-initiatives-national-health-information-technology
      November 03, 2015 - Review A comparative review of patient safety initiatives for national health information technology. Citation Text: Magrabi F, Aarts J, Nohr C, et al. A comparative review of patient safety initiatives for national health information technology. Int J Med Inform. 2013;82(5):e139-48. d…

2531. A survey of pharmacists' perception of the work environment and patient safety in community pharmacies during the COVID-19 pandemic. | PSNet
      psnet.ahrq.gov/issue/survey-pharmacists-perception-work-environment-and-patient-safety-community-pharmacies-during
      June 23, 2009 - Study A survey of pharmacists' perception of the work environment and patient safety in community pharmacies during the COVID-19 pandemic. Citation Text: Ljungberg Persson C, Nordén Hägg A, Södergård B. A survey of pharmacists' perception of the work environment and patient safety in com…

2532. Improving the governance of patient safety in emergency care: a systematic review of interventions. | PSNet
      psnet.ahrq.gov/issue/improving-governance-patient-safety-emergency-care-systematic-review-interventions
      March 06, 2013 - Review Improving the governance of patient safety in emergency care: a systematic review of interventions. Citation Text: Hesselink G, Berben S, Beune T, et al. Improving the governance of patient safety in emergency care: a systematic review of interventions. BMJ Open. 2016;6(1):e009837…

2533. The accuracy of medical dispatch—a systematic review. | PSNet
      psnet.ahrq.gov/issue/accuracy-medical-dispatch-systematic-review
      March 12, 2025 - Review The accuracy of medical dispatch—a systematic review. Citation Text: Bohm K, Kurland L. The accuracy of medical dispatch - a systematic review. Scand J Trauma Resusc Emerg Med. 2018;26(1):94. doi:10.1186/s13049-018-0528-8. Copy Citation Format: DOI Google Scholar Pub…

2534. Patient safety incidents associated with equipment in critical care: a review of reports to the UK National Patient Safety Agency. | PSNet
      psnet.ahrq.gov/issue/patient-safety-incidents-associated-equipment-critical-care-review-reports-uk-national
      November 29, 2023 - Study Patient safety incidents associated with equipment in critical care: a review of reports to the UK National Patient Safety Agency. Citation Text: Thomas AN, Galvin I. Patient safety incidents associated with equipment in critical care: a review of reports to the UK National Patie…

2535. Assessing the impact of a new pediatric healthcare facility on medication administration: a human factors approach. | PSNet
      psnet.ahrq.gov/issue/assessing-impact-new-pediatric-healthcare-facility-medication-administration-human-factors
      February 07, 2024 - Study Assessing the impact of a new pediatric healthcare facility on medication administration: a human factors approach. Citation Text: Godin MR, Nasr AS. Assessing the impact of a new pediatric healthcare facility on medication administration: a human factors approach. J Nurs Adm. 2023…

2536. How do we know when we have done enough? Ensuring sufficient patient notification efforts after a large-scale adverse event. | PSNet
      psnet.ahrq.gov/issue/how-do-we-know-when-we-have-done-enough-ensuring-sufficient-patient-notification-efforts
      August 18, 2021 - Commentary How do we know when we have done enough? Ensuring sufficient patient notification efforts after a large-scale adverse event. Citation Text: Alfandre D, Foglia MB, Holodniy M, et al. How do we know when we have done enough? Ensuring sufficient patient notification efforts after…

2537. Comments Due September 9 for New CMS Proposed Rule | The Academy
      integrationacademy.ahrq.gov/news-and-events/news/comments-due-september-9-new-cms-proposed-rule
      July 31, 2024 - An official website of the Department of Health & Human Services Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates The Academy Integrating Behavioral Health & Primary Care Expand Navi…

2538. Sharing lessons learned to prevent adverse events in anesthesiology nationwide. | PSNet
      psnet.ahrq.gov/issue/sharing-lessons-learned-prevent-adverse-events-anesthesiology-nationwide
      April 12, 2019 - Study Sharing lessons learned to prevent adverse events in anesthesiology nationwide. Citation Text: Soncrant C, Neily J, Sum-Ping SJT, et al. Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide. J Patient Saf. 2021;17(4):e343-e349. doi:10.1097/PTS.000000000000…

2539. Accurate measurement in California's safety-net health systems has gaps and barriers. | PSNet
      psnet.ahrq.gov/issue/accurate-measurement-californias-safety-net-health-systems-has-gaps-and-barriers
      April 04, 2018 - Study Accurate measurement in California's safety-net health systems has gaps and barriers. Citation Text: Khoong EC, Cherian R, Rivadeneira NA, et al. Accurate Measurement In California's Safety-Net Health Systems Has Gaps And Barriers. Health Aff (Millwood). 2018;37(11):1760-1769. doi:…

2540. Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration. | PSNet
      psnet.ahrq.gov/issue/errors-upstream-and-downstream-universal-protocol-associated-wrong-surgery-events-veterans
      November 21, 2012 - Study Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration. Citation Text: Paull DE, Mazzia L, Neily J, et al. Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in t…