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psnet.ahrq.gov/node/43749/psn-pdf
December 10, 2014 - Alarm management: first things first: using reliable data
to eliminate unnecessary alarms.
December 10, 2014
Vanderveen T. Patient Saf Qual Healthc. November/December 2014;11:38-40,42-45.
https://psnet.ahrq.gov/issue/alarm-management-first-things-first-using-reliable-data-eliminate-unnecessary-
alarms
Spotlightin…
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psnet.ahrq.gov/node/846159/psn-pdf
March 15, 2023 - Undertaking risk and relational work to manage
vulnerability: acute medical patients' involvement in
patient safety in the NHS.
March 15, 2023
Sutton E, Martin G, Eborall H, et al. Undertaking risk and relational work to manage vulnerability: acute
medical patients’ involvement in patient safety in the NHS. Soc Sc…
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psnet.ahrq.gov/node/42674/psn-pdf
September 12, 2016 - Using crew resource management and a 'read-and-do
checklist' to reduce failure-to-rescue events on a step-
down unit.
September 12, 2016
Young-Xu Y, Fore AM, Metcalf A, et al. Using crew resource management and a 'read-and-do checklist' to
reduce failure-to-rescue events on a step-down unit. Am J Nurs. 2013;113(9)…
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psnet.ahrq.gov/node/60804/psn-pdf
August 12, 2020 - Improved medication management with introduction of a
perioperative and prescribing pharmacist service.
August 12, 2020
Nguyen AD, Lam A, Banakh I, et al. Improved medication management with introduction of a perioperative
and prescribing pharmacist service. J Pharm Pract. 2020;33(3):299-305. doi:10.1177/0897190018…
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psnet.ahrq.gov/node/37805/psn-pdf
February 15, 2011 - Designing and implementing a comprehensive quality and
patient safety management model: a paradigm for
perioperative improvement.
February 15, 2011
Herzer KR, Mark LJ, Michelson JD, et al. Designing and Implementing a Comprehensive Quality and
Patient Safety Management Model. J Patient Saf. 2008;4(2). doi:10.1097/…
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psnet.ahrq.gov/node/41207/psn-pdf
September 27, 2016 - Improving patient safety and optimizing nursing
teamwork using crew resource management techniques.
September 27, 2016
West P, Sculli GL, Fore AM, et al. Improving patient safety and optimizing nursing teamwork using crew
resource management techniques. J Nurs Adm. 2012;42(1):15-20. doi:10.1097/NNA.0b013e31823c17c7…
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psnet.ahrq.gov/node/36463/psn-pdf
July 10, 2008 - Missed opportunities in the primary care management of
early acute ischemic heart disease.
July 10, 2008
Sequist TD, Marshall R, Lampert S, et al. Missed opportunities in the primary care management of early
acute ischemic heart disease. Arch Intern Med. 2006;166(20):2237-43.
https://psnet.ahrq.gov/issue/missed-op…
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psnet.ahrq.gov/node/41117/psn-pdf
March 04, 2015 - The effectiveness of integrated health information
technologies across the phases of medication
management: a systematic review of randomized
controlled trials.
March 4, 2015
McKibbon A, Lokker C, Handler S, et al. The effectiveness of integrated health information technologies
across the phases of medication man…
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psnet.ahrq.gov/node/41894/psn-pdf
January 01, 2016 - Simulator-based crew resource management training for
interhospital transfer of critically ill patients by a mobile
ICU.
January 9, 2013
Droogh JM, Kruger HL, Ligtenberg JJM, et al. Simulator-Based Crew Resource Management Training for
Interhospital Transfer of Critically Ill Patients by a Mobile ICU. Jt Comm J Qu…
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psnet.ahrq.gov/node/47775/psn-pdf
April 03, 2019 - Reducing diagnostic errors worldwide through diagnostic
management teams.
April 3, 2019
Verna R, Velazquez AB, Laposata M. Reducing Diagnostic Errors Worldwide Through Diagnostic
Management Teams. Ann Lab Med. 2019;39(2):121-124. doi:10.3343/alm.2019.39.2.121.
https://psnet.ahrq.gov/issue/reducing-diagnostic-error…
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psnet.ahrq.gov/issue/operating-management-system-high-reliability-leadership-accountability-learning-and
July 01, 2016 - Commentary
Operating management system for high reliability: leadership, accountability, learning and innovation in healthcare.
Citation Text:
Day RM, Demski RJ, Pronovost PJ, et al. Operating management system for high reliability: Leadership, accountability, learning and innovation in …
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND_0319_06-17-2009.pdf
January 01, 2009 - Effective Health Care
Topic Number(s): 0170
Document Completion Date: 1-13-10
1
Results of Topic Selection Process & Next Steps
The use of procalcitonin for the diagnosis and management of sepsis will go forward for refinement as
a systematic review. The scope of this topic, including popul…
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psnet.ahrq.gov/issue/deploying-and-measuring-risk-and-patient-safety-program
January 19, 2022 - Commentary
Deploying and measuring a risk and patient safety program.
Citation Text:
Orel H, McGroarty M, Marchegiani H. Deploying and measuring a risk and patient safety program. J Healthc Risk Manag. 2017;36(3):26-33. doi:10.1002/jhrm.21266.
Copy Citation
Format:
DOI Goog…
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digital.ahrq.gov/ahrq-funded-projects/enabling-health-care-decisionmaking-through-use-health-information-technology/annual-summary/2010
January 01, 2010 - Enabling Health Care Decisionmaking through the Use of Health Information Technology - 2010
Project Name
Enabling Health Care Decisionmaking through the Use of Health Information Technology
Principal Investigator
Lobach, David
Organization
Duke University
Contract Num…
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psnet.ahrq.gov/issue/matching-nurse-skill-patient-acuity-intensive-care-units-risk-management-mandate
April 24, 2018 - Commentary
Matching nurse skill with patient acuity in the intensive care units: a risk management mandate.
Citation Text:
Rischbieth A. Matching nurse skill with patient acuity in the intensive care units: a risk management mandate. J Nurs Manag. 2006;14(5):397-404.
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…
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psnet.ahrq.gov/issue/clinical-risk-management-and-patient-safety-education-nurses-critique
June 22, 2009 - Commentary
Clinical risk management and patient safety education for nurses: a critique.
Citation Text:
Johnstone M-J, Kanitsaki O. Clinical risk management and patient safety education for nurses: a critique. Nurse Educ Today. 2007;27(3):185-91.
Copy Citation
Format:
Goo…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20140115_DB/3_Deborah_Kilstein_slides_29-40.pdf
January 15, 2014 - Using the CAHPS Database to Compare, Report, and Improve Organizational Performance
CAHPS Sponsor Report
The ACAP Experience
Deborah Kilstein
ACAP Vice President, Quality Management and
Operational Support
January 15, 2014
29
Agenda
30
Who is ACAP?
Growing role of health plans
What …
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND_0715-140408.pdf
May 29, 2025 - Topic 0590 Strategies to Treat and Manage Infantile Hemangioma NSD FINAL_SJ
Strategies to Treat and Manage Infantile Hemangioma
Nomination Summary Document
…
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psnet.ahrq.gov/issue/pain-management-and-prescription-opioid-related-harms-exploring-state-evidence-proceedings
July 05, 2008 - Meeting/Conference Proceedings
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.
Citation Text:
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Works…
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…