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8841. Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. | PSNet
      psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome-human-error
      December 09, 2020 - Study Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. Citation Text: Hensley NB, Koch CG, Pronovost P, et al. Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Int…

8842. Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital. | PSNet
      psnet.ahrq.gov/issue/demonstrating-high-reliability-accountability-measures-johns-hopkins-hospital
      January 27, 2016 - Study Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital. Citation Text: Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531…

8843. Evaluation of AHRQ's On-time Pressure Ulcer Program | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/evaluation-ahrqs-time-pressure-ulcer-program
      January 01, 2023 - Evaluation of AHRQ's On-time Pressure Ulcer Program Project Description Annual Summaries Publications Project Details - Completed Contract Number 290-06-0011-8 Funding Mechanism(s) Accelerating Change and Transformation in O…

8844. Complication rates, hospital size, and bias in the CMS Hospital-Acquired Condition Reduction Program. | PSNet
      psnet.ahrq.gov/issue/complication-rates-hospital-size-and-bias-cms-hospital-acquired-condition-reduction-program
      October 19, 2022 - Study Complication rates, hospital size, and bias in the CMS Hospital-Acquired Condition Reduction Program. Citation Text: Koenig L, Soltoff SA, Demiralp B, et al. Complication Rates, Hospital Size, and Bias in the CMS Hospital-Acquired Condition Reduction Program. Am J Med Qual. 2017;32…

8845. Leadership behavior associations with domains of safety culture, engagement, and healthcare worker well-being. | PSNet
      psnet.ahrq.gov/issue/leadership-behavior-associations-domains-safety-culture-engagement-and-healthcare-worker-well
      February 24, 2021 - Study Leadership behavior associations with domains of safety culture, engagement, and healthcare worker well-being. Citation Text: Tawfik DS, Adair KC, Palassof S, et al. Leadership behavior associations with domains of safety culture, engagement, and healthcare worker well-being. Jt Co…

8846. Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years. | PSNet
      psnet.ahrq.gov/issue/insurance-claims-wrong-side-wrong-organ-wrong-procedure-or-wrong-person-surgical-errors
      October 20, 2021 - Study Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years. Citation Text: Vacheron C-H, Acker A, Autran M, et al. Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors:…

8847. The Virtual Patient for Improving Quality of Care in Primary Healthcare | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/virtual-patient-improving-quality-care-primary-healthcare
      January 01, 2023 - The Virtual Patient for Improving Quality of Care in Primary Healthcare Project Final Report ( PDF , 439.67 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent …

8848. Developing and Using Valid Clinical Quality Metrics for HIT - 2010 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/developing-and-using-valid-clinical-quality-metrics-health-information/annual-summary/2010
      January 01, 2010 - Developing and Using Valid Clinical Quality Metrics for HIT - 2010 Project Name Developing and Using Valid Clinical Quality Metrics for Health Information Technology (Health IT) with Health Information Exchange (HIE) Principal Investigator Kaushal, Rainu Organization Weill Me…

8849. Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers. | PSNet
      psnet.ahrq.gov/issue/assessment-incorrect-surgical-procedures-within-and-outside-operating-room-follow-study-us
      October 24, 2018 - Study Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers. Citation Text: Neily J, Soncrant C, Mills PD, et al. Assessment of Incorrect Surgical Procedures Within and Outside the Opera…

8850. COVID-19: patient safety and quality improvement skills to deploy during the surge. | PSNet
      psnet.ahrq.gov/issue/covid-19-patient-safety-and-quality-improvement-skills-deploy-during-surge
      March 23, 2022 - Commentary COVID-19: patient safety and quality improvement skills to deploy during the surge. Citation Text: Staines A, Amalberti R, Berwick DM, et al. COVID-19: patient safety and quality improvement skills to deploy during the surge. Int J Qual Health Care. 2021;33(1):mzaa050. doi:10.…

8851. Industrial and Systems Engineering and Health Care: Critical Areas of Research Workshop - Participants | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/industrial-systems-engineering-and-health-care-critical-areas-research-workshop/industrial-and-systems-engineering-and-health-care-critical-areas-research-workshop-participants
      January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…

8852. Medication Monitoring for Vulnerable Populations via Information Technology (MMITI) | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/medication-monitoring-vulnerable-populations-information-technology-mmiti
      January 01, 2023 - Medication Monitoring for Vulnerable Populations via Information Technology (MMITI) Project Final Report ( PDF , 323.72 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessaril…

8853. Influencing a culture of quality and safety through huddles. | PSNet
      psnet.ahrq.gov/issue/influencing-culture-quality-and-safety-through-huddles
      April 05, 2023 - Study Influencing a culture of quality and safety through huddles. Citation Text: McCain N, Ferguson T, Barry Hultquist T, et al. Influencing a culture of quality and safety through huddles. J Nurs Care Qual. 2023;38(1):26-32. doi:10.1097/ncq.0000000000000642. Copy Citation Format:…

8854. A qualitative exploration of mental health service user and carer perspectives on safety issues in UK mental health services. | PSNet
      psnet.ahrq.gov/issue/qualitative-exploration-mental-health-service-user-and-carer-perspectives-safety-issues-uk
      March 31, 2021 - Study A qualitative exploration of mental health service user and carer perspectives on safety issues in UK mental health services. Citation Text: Berzins K, Baker J, Louch G, et al. A qualitative exploration of mental health service user and carer perspectives on safety issues in UK men…

8855. Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital. | PSNet
      psnet.ahrq.gov/issue/healthcare-associated-adverse-events-alternate-level-care-patients-awaiting-long-term-care
      March 17, 2021 - Study Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital. Citation Text: Lim Fat GJ, Gopaul A, Pananos AD, et al. Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital. Geriat…

8856. Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility. | PSNet
      psnet.ahrq.gov/issue/disparate-perspectives-exploring-healthcare-professionals-misaligned-mental-models-older
      May 11, 2022 - Study Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility. Citation Text: Werner NE, Rutkowski RA, Krause S, et al. Disparate perspectives: exploring health…

8857. Use of heuristics during the clinical decision process from family care physicians in real conditions. | PSNet
      psnet.ahrq.gov/issue/use-heuristics-during-clinical-decision-process-family-care-physicians-real-conditions
      March 09, 2022 - Study Use of heuristics during the clinical decision process from family care physicians in real conditions. Citation Text: Fernández‐Aguilar C, Martín‐Martín JJ, Minué Lorenzo S, et al. Use of heuristics during the clinical decision process from family care physicians in real conditions…

8858. Using Health Information Technology to Improve Health Care Quality in Primary Care Practices and in Transitions between Care Settings - 2010 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/using-health-information-technology-improve-health-care-quality-primary-care-va/annual-summary/2010
      January 01, 2010 - Using Health Information Technology to Improve Health Care Quality in Primary Care Practices and in Transitions between Care Settings - 2010 Project Name Using Health Information Technology to Improve Health Care Quality in Primary Care Practices and in Transitions between Care Settings Prin…

8859. Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation. | PSNet
      psnet.ahrq.gov/issue/usability-human-factors-based-clinical-decision-support-emergency-department-lessons-learned
      January 08, 2020 - Study Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation. Citation Text: Salwei ME, Hoonakker PLT, Carayon P, et al. Usability of a human factors-based clinical decision support in the emergency departme…

8860. Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis. | PSNet
      psnet.ahrq.gov/issue/psychological-impact-and-recovery-after-involvement-patient-safety-incident-repeated-measures
      September 19, 2016 - Study Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis. Citation Text: Van Gerven E, Bruyneel L, Panella M, et al. Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis.…