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psnet.ahrq.gov/issue/impact-improving-teamwork-patient-outcomes-surgery-systematic-review
May 13, 2020 - Review
The impact of improving teamwork on patient outcomes in surgery: a systematic review.
Citation Text:
Sun R, Marshall DC, Sykes MC, et al. The impact of improving teamwork on patient outcomes in surgery: A systematic review. Int J Surg. 2018;53:171-177. doi:10.1016/j.ijsu.2018.03.0…
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psnet.ahrq.gov/issue/implementing-rise-second-victim-support-programme-johns-hopkins-hospital-case-study
March 03, 2019 - Study
Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study.
Citation Text:
Edrees HH, Connors C, Paine LA, et al. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. BMJ Open. 2016;6(9):e011708. d…
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psnet.ahrq.gov/issue/deficiencies-emergent-and-outpatient-care-patient-alcohol-use-disorder-richard-l-roudebush-va
July 13, 2022 - Book/Report
Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.
Citation Text:
Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Rou…
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psnet.ahrq.gov/issue/cybersecurity-health-urgent-patient-safety-concern-we-can-learn-existing-patient-safety
October 28, 2020 - Commentary
Cybersecurity in health is an urgent patient safety concern: we can learn from existing patient safety improvement strategies to address it.
Citation Text:
O’Brien N, Ghafur S, Durkin M. Cybersecurity in health is an urgent patient safety concern: we can learn from existing pa…
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psnet.ahrq.gov/issue/burnout-mediates-association-between-depression-and-patient-safety-perceptions-cross
June 30, 2021 - Study
Burnout mediates the association between depression and patient safety perceptions: a cross-sectional study in hospital nurses.
Citation Text:
Johnson J, Louch G, Dunning A, et al. Burnout mediates the association between depression and patient safety perceptions: a cross-sectional…
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psnet.ahrq.gov/issue/effect-warning-symbols-combination-education-frequency-erroneously-crushing-medication
March 04, 2011 - Study
Effect of warning symbols in combination with education on the frequency of erroneously crushing medication in nursing homes: an uncontrolled before and after study.
Citation Text:
van Welie S, Wijma L, Beerden T, et al. Effect of warning symbols in combination with education on th…
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psnet.ahrq.gov/issue/supporting-doctors-healthcare-quality-and-safety-advocates-recommendations-association
April 13, 2016 - Study
Supporting doctors as healthcare quality and safety advocates: recommendations from the Association of Surgeons in Training (ASiT).
Citation Text:
Fleming CA, Humm G, Wild JR, et al. Supporting doctors as healthcare quality and safety advocates: Recommendations from the Association…
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psnet.ahrq.gov/issue/analysis-consistency-emergency-department-physician-variation-propensity-admission-across
May 19, 2021 - Study
Analysis of consistency in emergency department physician variation in propensity for admission across patient sociodemographic groups.
Citation Text:
Khidir H, McWilliams JM, O’Malley AJ, et al. Analysis of consistency in emergency department physician variation in propensity for …
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psnet.ahrq.gov/issue/war-two-fronts-cancer-care-time-covid-19
March 12, 2025 - Commentary
A war on two fronts: cancer care in the time of COVID-19.
Citation Text:
Kutikov A, Weinberg DS, Edelman MJ, et al. A war on two fronts: cancer care in the time of COVID-19. Ann Intern Med. 2020;172(11):756-758. doi:10.7326/m20-1133.
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psnet.ahrq.gov/issue/dashboard-design-identify-and-balance-competing-risk-multiple-hospital-acquired-conditions
December 16, 2020 - Study
Dashboard design to identify and balance competing risk of multiple hospital-acquired conditions.
Citation Text:
Makic MBF, Stevens KR, Gritz RM, et al. Dashboard design to identify and balance competing risk of multiple hospital-acquired conditions. Appl Clin Inform. 2022;13(3):62…
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psnet.ahrq.gov/issue/adopting-high-reliability-organization-principles-lead-large-scale-clinical-transformation
November 21, 2021 - Commentary
Adopting high reliability organization principles to lead a large scale clinical transformation.
Citation Text:
Pozzobon LD, Lam J, Chimonides E, et al. Adopting high reliability organization principles to lead a large scale clinical transformation. Healthc Manage Forum. 2023;…
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psnet.ahrq.gov/issue/improving-reliability-verbal-communication-between-primary-care-physicians-and-pediatric
November 16, 2015 - Study
Improving the reliability of verbal communication between primary care physicians and pediatric hospitalists at hospital discharge.
Citation Text:
Mussman GM, Vossmeyer MT, Brady PW, et al. Improving the reliability of verbal communication between primary care physicians and pediat…
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psnet.ahrq.gov/issue/accuracy-and-safety-medication-histories-obtained-time-intensive-care-unit-admission
October 20, 2021 - Study
Accuracy and safety of medication histories obtained at the time of intensive care unit admission of delirious or mechanically ventilated patients.
Citation Text:
Cicci CD, Fudzie SS, Campbell-Bright S, et al. Accuracy and safety of medication histories obtained at the time of inte…
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psnet.ahrq.gov/issue/roles-and-role-ambiguity-patient-and-caregiver-performed-outpatient-parenteral-antimicrobial
November 20, 2024 - Study
Roles and role ambiguity in patient- and caregiver-performed outpatient parenteral antimicrobial therapy.
Citation Text:
Keller SC, Cosgrove SE, Arbaje AI, et al. Roles and Role Ambiguity in Patient- and Caregiver-Performed Outpatient Parenteral Antimicrobial Therapy. Jt Comm J Qua…
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www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual/procedure-manual-appendix-iv-roles-and-responsibilities-uspstf-members-serving-topic-lead
July 01, 2017 - staff solicits volunteers for the position of primary lead from among assigned topic leads during work plan … The leads' role on a topic begins once they have received a draft work plan on the topic. … A call is then scheduled to discuss the draft work plan. … the research plan as final. … Reviewing every comment received from the public on the draft research plan and bringing other leads
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digital.ahrq.gov/sites/default/files/docs/page/2006Dye_051111comp.pdf
June 05, 2006 - chart reviews
• Trigger tool developed based on IHI
methodology
7
Medication Error Assessment Plan … meds
Many forms/doses/quantities
Adding doses to food/feeds
13
Medication Error Assessment Plan … Pediatrics: Special challenges
3-pronged approach to measuring events
Medication Error Assessment Plan … Medication Error Assessment Plan (cont'd.) … Observation
Medication Error Assessment Plan
Trigger Tool Chart Reviews
Medication Error Assessment
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effectivehealthcare.ahrq.gov/sites/default/files/pregnancy-horizon-scan-high-impact-1312.pdf
December 01, 2013 - Overall high-impact potential: vending machine dispensers for emergency oral
contraceptive (Plan B … *Vending machine dispensers for emergency oral contraceptive
(Plan B One-Step) to prevent pregnancy … Plan B One-Step pricing. [internet]. Santa Monica
(CA): GoodRx, Inc. … Available: http://www.goodrx.com/plan-b-
one-step.
7. … Obama administration
drops its appeal of Plan B ruling, will widen
access to drug. [internet].
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psnet.ahrq.gov/node/34692/psn-pdf
February 10, 2011 - The economic consequences of medical injuries:
implications for a no-fault insurance plan. … Implications for a no-fault insurance plan. JAMA. 1992;267(18):2487-92. … https://psnet.ahrq.gov/issue/economic-consequences-medical-injuries-implications-no-fault-insurance-plan … https://psnet.ahrq.gov/issue/economic-consequences-medical-injuries-implications-no-fault-insurance-plan
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hcup-us.ahrq.gov/reports/race/annotatedslidesforR_E_report2.jsp
May 01, 2016 - Office of Minority Health: National Partnership for Action to End Health Disparities' National Plan … Racial and Ethnic Health Disparities in Colorado 2009
Colorado Health Disparities Strategic Plan … to Eliminate Minority Health Disparities Plan of Action 2010-2014
NJ
Strategic Plans … for Action
Heart Disease and Stroke Prevention Rhode Island State Plan 2009
Reducing the Burden … Ethnicity: 2010
Action Plan to Eliminate Racial/Ethnic Health Disparities in the State of Utah
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meps.ahrq.gov/data_files/publications/st18/stat18.pdf
January 01, 2000 - than in a single coverage plan. … While almost
one-third of private-sector employees with single coverage were enrolled in a plan that … and small employers, employees
with single coverage were much less likely to contribute toward their plan … In contrast, single plan employee
contributions were greater in larger firms than smaller firms by about … If a plan
offers more than one arrangement for family coverage, premium information for a family of