-
psnet.ahrq.gov/issue/parenteral-opioid-shortage-treating-pain-during-opioid-overdose-epidemic
January 31, 2024 - Commentary
Emerging Classic
Parenteral opioid shortage—treating pain during the opioid-overdose epidemic.
Citation Text:
Bruera E. Parenteral Opioid Shortage - Treating Pain during the Opioid-Overdose Epidemic. N Engl J Med. 2018;379(7):601-603. doi:10.1056/NEJM…
-
psnet.ahrq.gov/issue/unintended-errors-ehr-based-result-management-case-series
April 29, 2018 - Commentary
Unintended errors with EHR-based result management: a case series.
Citation Text:
Yackel TR, Embi P. Unintended errors with EHR-based result management: a case series. J Am Med Inform Assoc. 2010;17(1):104-7. doi:10.1197/jamia.M3294.
Copy Citation
Format:
DOI G…
-
psnet.ahrq.gov/issue/hospital-prescribing-opioids-medicare-beneficiaries
December 04, 2016 - Study
Hospital prescribing of opioids to Medicare beneficiaries.
Citation Text:
Jena AB, Goldman D, Karaca-Mandic P. Hospital Prescribing of Opioids to Medicare Beneficiaries. JAMA Intern Med. 2016;176(7):990-7. doi:10.1001/jamainternmed.2016.2737.
Copy Citation
Format:
DOI…
-
psnet.ahrq.gov/issue/impact-and-implementation-simulation-based-training-safety
August 02, 2023 - Review
Impact and implementation of simulation-based training for safety.
Citation Text:
Bilotta FF, Werner SM, Bergese SD, et al. Impact and implementation of simulation-based training for safety. ScientificWorldJournal. 2013;2013:652956. doi:10.1155/2013/652956.
Copy Citation
F…
-
psnet.ahrq.gov/issue/culture-safety-results-organization-wide-survey-15-california-hospitals
November 18, 2009 - Study
Classic
The culture of safety: results of an organization-wide survey in 15 California hospitals.
Citation Text:
Singer SJ, Gaba DM, Geppert JJ, et al. The culture of safety: results of an organization-wide survey in 15 California hospitals. Qual Saf Hea…
-
psnet.ahrq.gov/issue/just-culture-its-more-policy
July 05, 2017 - Study
Just culture: it's more than policy.
Citation Text:
Paradiso L, Sweeney N. Just culture: It's more than policy. Nurs Manage. 2019;50(6):38-45. doi:10.1097/01.NUMA.0000558482.07815.ae.
Copy Citation
Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML …
-
psnet.ahrq.gov/issue/view-cockpit-what-airline-industry-can-teach-us-about-patient-safety
January 08, 2020 - Commentary
View from the cockpit: what the airline industry can teach us about patient safety.
Citation Text:
Doucette JN. View from the cockpit: what the airline industry can teach us about patient safety. Nursing (Brux). 2006;36(11):50-53.
Copy Citation
Format:
Google S…
-
psnet.ahrq.gov/issue/rapid-response-teams-qualitative-analysis-their-effectiveness
November 02, 2010 - Study
Rapid response teams: qualitative analysis of their effectiveness.
Citation Text:
Leach LS, Mayo AM. Rapid response teams: qualitative analysis of their effectiveness. Am J Crit Care. 2013;22(3):198-210. doi:10.4037/ajcc2013990.
Copy Citation
Format:
DOI Google Schol…
-
psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005-developing-error-reporting-system-improve
January 14, 2011 - Commentary
The Patient Safety and Quality Improvement Act of 2005: developing an error reporting system to improve patient safety.
Citation Text:
Riley W, Liang BA, Rutherford W, et al. The Patient Safety and Quality Improvement Act of 2005. J Patient Saf. 2008;4(1). doi:10.1097/pts.0b…
-
psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005-provisions-and-potential-opportunities
February 15, 2011 - Commentary
The Patient Safety and Quality Improvement Act of 2005: provisions and potential opportunities.
Citation Text:
Liang BA, Riley W, Rutherford W, et al. The Patient Safety and Quality Improvement Act of 2005: Provisions and Potential Opportunities. American Journal of Medical …
-
psnet.ahrq.gov/issue/improving-pathologists-communication-skills
May 18, 2022 - Commentary
Improving pathologists' communication skills.
Citation Text:
Dintzis SM. Improving Pathologists' Communication Skills. AMA J Ethics. 2016;18(8):802-8. doi:10.1001/journalofethics.2016.18.8.medu1-1608.
Copy Citation
Format:
DOI Google Scholar PubMed BibTeX EndNote…
-
psnet.ahrq.gov/issue/factors-influencing-preceptors-responses-medical-errors-factorial-survey
September 10, 2009 - Study
Factors influencing preceptors' responses to medical errors: a factorial survey.
Citation Text:
Mazor KM, Fischer M, Haley H-L, et al. Factors influencing preceptors' responses to medical errors: a factorial survey. Acad Med. 2005;80(10 Suppl):S88-92.
Copy Citation
Format: …
-
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-starting-practice.pdf
June 02, 2025 - Job Aid: Starting with a Practice
Primary Care Practice Facilitator
Training Series
1
Job Aid: Starting with a Practice
Overview
How you start with a practice can set the tone for your work with the practice. Do your
homework and be well prepared for all of your meetings. Spend time getting to know…
-
psnet.ahrq.gov/issue/medical-students-experiences-medical-errors-analysis-medical-student-essays
June 22, 2022 - Study
Medical students' experiences with medical errors: an analysis of medical student essays.
Citation Text:
Martinez W, Lo B. Medical students' experiences with medical errors: an analysis of medical student essays. Med Educ. 2008;42(7):733-41. doi:10.1111/j.1365-2923.2008.03109.x. …
-
psnet.ahrq.gov/issue/quality-improvement-universal-protocol-use-office-based-gastrointestinal-procedure-units
November 16, 2022 - Commentary
Quality improvement: Universal Protocol use in office-based gastrointestinal procedure units.
Citation Text:
Hardee LK. Quality improvement: universal protocol use in office-based gastrointestinal procedure units. Gastroenterol Nurs. 2012;35(6):380-2. doi:10.1097/SGA.0b013e3…
-
psnet.ahrq.gov/issue/whats-sound-managing-alarm-fatigue
April 26, 2023 - Newspaper/Magazine Article
What's that sound? Managing alarm fatigue.
Citation Text:
George TP, Martin V. Whatʼs that sound? Managing alarm fatigue. Nursing Made Incredibly Easy!. 2014;12(5). doi:10.1097/01.nme.0000452689.19763.3f.
Copy Citation
Format:
DOI Google Scholar B…
-
psnet.ahrq.gov/issue/supervision-autonomy-and-medical-error-teaching-clinic
November 26, 2014 - Commentary
Supervision, autonomy, and medical error in the teaching clinic.
Citation Text:
Cossman JP, Wang M, Fischer AA. Supervision, autonomy, and medical error in the teaching clinic. J Am Acad Dermatol. 2018;79(5):981-983. doi:10.1016/j.jaad.2017.12.033.
Copy Citation
Format: …
-
psnet.ahrq.gov/issue/reducing-administrative-harm-medicine-clinicians-and-administrators-together
February 23, 2022 - Commentary
Reducing administrative harm in medicine - clinicians and administrators together.
Citation Text:
O’Donnell WJ. Reducing administrative harm in medicine - clinicians and administrators together. N Engl J Med. 2022;386(25):2429-2432. doi:10.1056/nejmms2202174.
Copy Citation
…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool10_dc_checklist.docx
November 01, 2015 - Tool 10: Discharge Process Checklist
Tool 10: Discharge PROCESS Checklist
Purpose
Provide updated guidance to readmission reduction teams for updating discharge processes, based on Centers for Medicare & Medicaid Services (CMS) documents.
Description
This tool, adapted from the CMS Conditions of Participation (CO…
-
www.ahrq.gov/news/newsroom/case-studies/201524.html
August 01, 2015 - Aurora Health Care Embraces AHRQ’s CUSP Method to Protect Patient Safety
Search All Impact Case Studies
August 2015
Fourteen hospitals operated by Aurora Health Care in eastern Wisconsin reduced central line-associated bloodstream infections (CLABSI) in intensive care units by 65 percent after adopting pat…