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psnet.ahrq.gov/issue/multiple-points-system-failure-underpin-continuous-subcutaneous-infusion-safety-incidents
December 16, 2020 - Study
Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: a mixed methods analysis.
Citation Text:
Brown AJ, Yardley S, Bowers B, et al. Multiple points of system failure underpin continuous subcutaneous infusion safety inciden…
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psnet.ahrq.gov/issue/assessment-patient-preferred-language-achieve-goal-aligned-deprescribing-older-adults
December 19, 2018 - Study
Assessment of patient-preferred language to achieve goal-aligned deprescribing in older adults.
Citation Text:
Green AR, Aschmann H, Boyd CM, et al. Assessment of patient-preferred language to achieve goal-aligned deprescribing in older adults. JAMA Netw Open. 2021;4(4):e212633. do…
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psnet.ahrq.gov/issue/effectiveness-tele-triage-during-covid-19-pandemic-systematic-review-and-narrative-synthesis
February 01, 2023 - Review
The effectiveness of tele-triage during the COVID-19 pandemic: a systematic review and narrative synthesis.
Citation Text:
Farzandipour M, Nabovati E, Sharif R. The effectiveness of tele-triage during the COVID-19 pandemic: a systematic review and narrative synthesis. J Telemed Te…
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psnet.ahrq.gov/issue/patient-perspectives-how-physicians-communicate-diagnostic-uncertainty-experimental-vignette
August 07, 2019 - Study
Classic
Patient perspectives on how physicians communicate diagnostic uncertainty: an experimental vignette study.
Citation Text:
Bhise V, Meyer AND, Menon S, et al. Patient perspectives on how physicians communicate diagnostic uncertainty: An experimental…
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psnet.ahrq.gov/issue/identifying-barriers-and-opportunities-telehealth-implementation-amidst-covid-19-pandemic
July 07, 2021 - Commentary
Identifying barriers to and opportunities for telehealth implementation amidst the COVID-19 pandemic by using a human factors approach: a leap into the future of health care delivery?
Citation Text:
Zhang T, Mosier J, Subbian V. Identifying barriers to and opportunities for te…
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psnet.ahrq.gov/issue/does-crew-resource-management-training-work-update-extension-and-some-critical-needs
January 02, 2017 - Review
Does crew resource management training work? An update, an extension, and some critical needs.
Citation Text:
Salas E, Wilson KA, Burke CS, et al. Does Crew Resource Management Training Work? An Update, an Extension, and Some Critical Needs. Hum Factors. 2006;48(2):392-412. doi:…
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psnet.ahrq.gov/issue/improving-patient-safety-public-hospitals-developing-standard-measures-track-medical-errors
December 19, 2018 - Study
Improving patient safety in public hospitals: developing standard measures to track medical errors and process breakdowns.
Citation Text:
Ackerman SL, Gourley G, Le G, et al. Improving Patient Safety in Public Hospitals: Developing Standard Measures to Track Medical Errors and Proc…
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psnet.ahrq.gov/issue/minimization-occurrence-retained-surgical-items-using-machine-learning-and-deep-learning
July 06, 2012 - Review
Minimization of occurrence of retained surgical items using machine learning and deep learning techniques: a review.
Citation Text:
Abo-Zahhad M, El-Malek AHA, Sayed MS, et al. Minimization of occurrence of retained surgical items using machine learning and deep learning technique…
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psnet.ahrq.gov/issue/client-caregiver-and-provider-perspectives-safety-palliative-home-care-mixed-method-design
March 02, 2016 - Study
Client, caregiver, and provider perspectives of safety in palliative home care: a mixed method design.
Citation Text:
Lang A, Toon L, Cohen SR, et al. Client, caregiver, and provider perspectives of safety in palliative home care: a mixed method design. Safety Health. 2015;1(1):3. …
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psnet.ahrq.gov/issue/how-improve-delivery-medication-alerts-within-computerized-physician-order-entry-systems
October 30, 2013 - Study
How to improve the delivery of medication alerts within computerized physician order entry systems: an international Delphi study.
Citation Text:
Riedmann D, Jung M, Hackl WO, et al. How to improve the delivery of medication alerts within computerized physician order entry systems:…
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www.ahrq.gov/news/newsroom/case-studies/201905.html
September 01, 2019 - University of Texas Health at San Antonio, University Health System Used AHRQ Tools
Search All Impact Case Studies
July 2019
The University of Texas Health at San Antonio (UT Health SA) used three AHRQ tools as the basis for developing a multimedia decision aid to help patients fully understand and consent …
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psnet.ahrq.gov/issue/hospital-wide-code-rates-and-mortality-and-after-implementation-rapid-response-team
October 17, 2011 - Study
Classic
Hospital-wide code rates and mortality before and after implementation of a rapid response team.
Citation Text:
Chan PS, Khalid A, Longmore LS, et al. Hospital-wide code rates and mortality before and after implementation of a rapid response team…
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psnet.ahrq.gov/issue/evaluation-hand-hygiene-intensive-care-unit-are-visitors-potential-vector-pathogens
April 22, 2015 - Study
An evaluation of hand hygiene in an intensive care unit: are visitors a potential vector for pathogens?
Citation Text:
Birnbach DJ, Rosen LF, Fitzpatrick M, et al. An evaluation of hand hygiene in an intensive care unit: Are visitors a potential vector for pathogens? J Infect Publi…
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psnet.ahrq.gov/issue/learning-patient-safety-incidents-incident-review-meetings-organisational-factors-and
December 29, 2014 - Study
Learning from patient safety incidents in incident review meetings: organisational factors and indicators of analytic process effectiveness.
Citation Text:
Anderson JE, Kodate N. Learning from patient safety incidents in incident review meetings: Organisational factors and indicato…
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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