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psnet.ahrq.gov/node/44881/psn-pdf
August 16, 2017 - A comparative effectiveness analysis of the
implementation of surgical safety checklists in a tertiary
care hospital.
August 16, 2017
Bock M, Fanolla A, Segur-Cabanac I, et al. A Comparative Effectiveness Analysis of the Implementation of
Surgical Safety Checklists in a Tertiary Care Hospital. JAMA Surg. 2016;151(…
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psnet.ahrq.gov/node/46245/psn-pdf
June 28, 2017 - Associations between patient factors and adverse events
in the home care setting: a secondary data analysis of
two Canadian adverse event studies.
June 28, 2017
Sears NA, Blais R, Spinks M, et al. Associations between patient factors and adverse events in the home
care setting: a secondary data analysis of two can…
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psnet.ahrq.gov/node/47006/psn-pdf
October 13, 2018 - Assessment of the safety of discharging select patients
directly home from the intensive care unit: a multicenter
population-based cohort study.
October 13, 2018
Stelfox HT, Soo A, Niven DJ, et al. Assessment of the Safety of Discharging Select Patients Directly Home
From the Intensive Care Unit: A Multicenter Pop…
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psnet.ahrq.gov/node/44715/psn-pdf
May 19, 2019 - Electronic health record–related events in medical
malpractice claims.
May 19, 2019
Graber ML, Siegal D, Riah H, et al. Electronic Health Record-Related Events in Medical Malpractice
Claims. J Patient Saf. 2019;15(2):77-85. doi:10.1097/PTS.0000000000000240.
https://psnet.ahrq.gov/issue/electronic-health-record-rel…
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psnet.ahrq.gov/node/48130/psn-pdf
August 07, 2019 - Adverse events in long-term care residents transitioning
from hospital back to nursing home.
August 7, 2019
Kapoor A, Field T, Handler S, et al. Adverse Events in Long-term Care Residents Transitioning From
Hospital Back to Nursing Home. JAMA Intern Med. 2019;179(9):1254-1261.
doi:10.1001/jamainternmed.2019.2005.
…
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psnet.ahrq.gov/node/44671/psn-pdf
September 20, 2016 - Primary care physicians' willingness to disclose oncology
errors involving multiple providers to patients.
September 20, 2016
Mazor KM, Roblin DW, Greene SM, et al. Primary care physicians' willingness to disclose oncology errors
involving multiple providers to patients. BMJ Qual Saf. 2016;25(10):787-95. doi:10.113…
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psnet.ahrq.gov/node/47372/psn-pdf
January 01, 2019 - Patient safety culture, health information technology
implementation, and medical office problems that could
lead to diagnostic error.
October 3, 2018
Campione JR, Mardon RE, McDonald KM. Patient Safety Culture, Health Information Technology
Implementation, and Medical Office Problems That Could Lead to Diagnostic…
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psnet.ahrq.gov/node/38900/psn-pdf
January 03, 2017 - Dropping the baton during the handoff from emergency
department to primary care: pediatric asthma continuity
errors.
January 3, 2017
Hsiao AL, Shiffman RN. Dropping the baton during the handoff from emergency department to primary
care: pediatric asthma continuity errors. Jt Comm J Qual Patient Saf. 2009;35(9):467…
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psnet.ahrq.gov/node/38816/psn-pdf
July 29, 2009 - Uncovering system errors using a rapid response team:
cross-coverage caught in the crossfire.
July 29, 2009
Kaplan LJ, Maerz LL, Schuster KM, et al. Uncovering System Errors Using a Rapid Response Team:
Cross-Coverage Caught in the Crossfire. The Journal of Trauma: Injury, Infection, and Critical Care.
2009;67(1).…
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psnet.ahrq.gov/node/41866/psn-pdf
November 28, 2012 - "It's like two worlds apart": an analysis of vulnerable
patient handover practices at discharge from hospital.
November 28, 2012
Groene RO, Orrego C, Suñol R, et al. "It's like two worlds apart": an analysis of vulnerable patient handover
practices at discharge from hospital. BMJ Qual Saf. 2012;21 Suppl 1:i67-75. d…
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psnet.ahrq.gov/node/41535/psn-pdf
December 31, 2014 - Understanding and preventing wrong-patient electronic
orders: a randomized controlled trial.
December 31, 2014
Adelman JS, Kalkut GE, Schechter CB, et al. Understanding and preventing wrong-patient electronic
orders: a randomized controlled trial. J Am Med Inform Assoc. 2013;20(2):305-310. doi:10.1136/amiajnl-
201…
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psnet.ahrq.gov/node/42454/psn-pdf
September 09, 2013 - A perinatal care quality and safety initiative: are there
financial rewards for improved quality?
September 9, 2013
Kozhimannil KB, Sommerness SA, Rauk P, et al. A perinatal care quality and safety initiative: are there
financial rewards for improved quality? Jt Comm J Qual Patient Saf. 2013;39(8):339-48.
https://…
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psnet.ahrq.gov/node/45714/psn-pdf
December 20, 2017 - US emergency department visits for outpatient adverse
drug events, 2013–2014.
December 20, 2017
Shehab N, Lovegrove MC, Geller AI, et al. US Emergency Department Visits for Outpatient Adverse Drug
Events, 2013-2014. JAMA. 2016;316(20):2115-2125. doi:10.1001/jama.2016.16201.
https://psnet.ahrq.gov/issue/us-emergenc…
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psnet.ahrq.gov/node/46507/psn-pdf
October 11, 2017 - Outcomes in two Massachusetts hospital systems give
reason for optimism about communication-and-resolution
programs.
October 11, 2017
Mello MM, Kachalia A, Roche S, et al. Outcomes In Two Massachusetts Hospital Systems Give Reason
For Optimism About Communication-And-Resolution Programs. Health Aff (Millwood). 201…
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psnet.ahrq.gov/glossary/handoffs-and-handovers
September 13, 2021 - Handoffs and Handovers
September 13, 2021
Anonymous (not verified)
See Primer . The process when one health care professional updates another on the status of one or more patients for the purpose of taking over their care. Typical examples involve a physician who has been on call overnight telling an incoming …
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digital.ahrq.gov/principal-investigator/yellowlees-peter-m
February 28, 2023 - Yellowlees, Peter M.
A Clinical Trial to Validate an Automated Online Language Interpreting Tool With Hispanic Patients Who Have Limited English Proficiency - Final Report
Citation
Yellowlees P. A Clinical Trial to Validate an Automated Online Language Interpreting Tool With H…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/histogram
January 01, 2023 - Histogram
Also Known As
Frequency Distribution
Description
A histogram graphically demonstrates the frequency with which various values of a particular variable occur in a set of data. The height of the bar indicates the frequency of occurrence.
Uses
To quickly and easily demonst…
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hcup-us.ahrq.gov/reports/factsandfigures/2008/pdfs/section5_4.pdf
January 01, 2008 - HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2008 64
EXHIBIT 5.4 MH and SA Inpatient Hospital Discharges Against Medical Advice
All Other
Diagnoses
292,300
79%
MH
25,000
7%
SA
52,700
14%
* Based on principal CCS diagnosis.
Source: AHRQ, Center for Delivery, Organiza…
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psnet.ahrq.gov/node/46902/psn-pdf
August 20, 2018 - Making soft intelligence hard: a multi-site qualitative
study of challenges relating to voice about safety
concerns.
August 20, 2018
Martin G, Aveling E-L, Campbell A, et al. Making soft intelligence hard: a multi-site qualitative study of
challenges relating to voice about safety concerns. BMJ Qual Saf. 2018;27(9…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/workflow-diagram
January 01, 2023 - Workflow Diagram
Also Known As
Physical Layout Flowchart
Spaghetti Diagram
Transportation Diagram
Description
A workflow diagram demonstrates movement through a process. The diagram is comprised of a map (such as a floor plan) of the area where the process occurs and uses lines to show…