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psnet.ahrq.gov/issue/influence-formulation-and-medicine-delivery-system-medication-administration-errors-care
March 23, 2011 - Study
The influence of formulation and medicine delivery system on medication administration errors in care homes for older people.
Citation Text:
Alldred DP, Standage C, Fletcher O, et al. The influence of formulation and medicine delivery system on medication administration errors in…
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psnet.ahrq.gov/issue/practically-speaking-rethinking-hand-hygiene-improvement-programs-health-care-settings
September 03, 2011 - Study
Practically speaking: rethinking hand hygiene improvement programs in health care settings.
Citation Text:
Son C, Chuck T, Childers T, et al. Practically speaking: Rethinking hand hygiene improvement programs in health care settings. Am J Infect Control. 2011;39(9). doi:10.1016/j…
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psnet.ahrq.gov/issue/overview-use-and-implementation-checklists-surgical-specialities-systematic-review
July 31, 2013 - Review
An overview of the use and implementation of checklists in surgical specialities - a systematic review.
Citation Text:
Patel J, Ahmed K, Guru KA, et al. An overview of the use and implementation of checklists in surgical specialities - a systematic review. Int J Surg. 2014;12(12):…
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psnet.ahrq.gov/issue/error-disclosure-and-family-members-reactions-does-type-error-really-matter
March 08, 2023 - Study
Error disclosure and family members' reactions: does the type of error really matter?
Citation Text:
Leone D, Lamiani G, Vegni E, et al. Error disclosure and family members' reactions: does the type of error really matter? Patient Educ Couns. 2015;98(4):446-52. doi:10.1016/j.pec.20…
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psnet.ahrq.gov/issue/effect-automated-alerts-provider-ordering-behavior-outpatient-setting
November 23, 2016 - Study
The effect of automated alerts on provider ordering behavior in an outpatient setting.
Citation Text:
Steele AW, Eisert S, Witter J, et al. The effect of automated alerts on provider ordering behavior in an outpatient setting. PLoS Med. 2005;2(9):e255. doi:10.1371/journal.pmed.…
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psnet.ahrq.gov/issue/teamwork-time-covid-19
November 16, 2022 - Commentary
Teamwork in the time of COVID-19.
Citation Text:
Takizawa PA, Honan L, Brissette D, et al. Teamwork in the time of COVID‐19. FASEB Bioadv. 2020;3(3):175-181. doi:10.1096/fba.2020-00093.
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psnet.ahrq.gov/issue/simulation-based-medical-error-disclosure-training-pediatric-healthcare-professionals
April 11, 2011 - Study
Simulation-based medical error disclosure training for pediatric healthcare professionals.
Citation Text:
Wayman KI, Yaeger KA, Sharek PJ, et al. Simulation-based medical error disclosure training for pediatric healthcare professionals. J Healthc Qual. 2007;29(4):12-9.
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psnet.ahrq.gov/issue/using-simulation-based-training-improve-patient-safety-what-does-it-take
August 30, 2006 - Commentary
Using simulation-based training to improve patient safety: what does it take?
Citation Text:
Salas E, Wilson K, Burke S, et al. Using simulation-based training to improve patient safety: what does it take? Jt Comm J Qual Patient Saf. 2005;31(7):363-71.
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psnet.ahrq.gov/issue/reflection-adverse-event-disclosure-postsurgical-hospital-context
August 20, 2018 - Commentary
Reflection on adverse event disclosure in the postsurgical hospital context.
Citation Text:
Roberts F, Gettings P, Torbeck L, et al. Reflection on adverse event disclosure in the postsurgical hospital context. J Surg Educ. 2015;72(4):767-70. doi:10.1016/j.jsurg.2014.12.016.
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psnet.ahrq.gov/issue/implementing-patient-safety-and-quality-program-across-two-merged-pediatric-institutions
June 03, 2013 - Study
Implementing a patient safety and quality program across two merged pediatric institutions.
Citation Text:
Abramson EL, Hyman D, Osorio N, et al. Implementing a patient safety and quality program across two merged pediatric institutions. Jt Comm J Qual Patient Saf. 2009;35(1):43-…
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psnet.ahrq.gov/issue/when-doing-wrong-feels-so-right-normalization-deviance
September 03, 2011 - Review
When doing wrong feels so right: normalization of deviance.
Citation Text:
Price MR, Williams TC. When Doing Wrong Feels So Right: Normalization of Deviance. J Patient Saf. 2018;14(1):1-2. doi:10.1097/PTS.0000000000000157.
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psnet.ahrq.gov/issue/improving-transitions-care-patients-warfarin-safe-transitions-anticoagulation-report
April 22, 2011 - Study
Improving transitions of care for patients on warfarin: the Safe Transitions Anticoagulation Report.
Citation Text:
Dunn AS, Shetreat-Klein A, Berman J, et al. Improving transitions of care for patients on warfarin: The safe transitions anticoagulation report. J Hosp Med. 2015;10(9…
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www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/carecoordination.html
June 01, 2018 - Chartbook on Care Coordination
Care Coordination
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Table of Contents
Chartbook on Care Coordination
Acknowledgments
Care Coordination
Trends in Care Coordination Measures
Transitions of Care
Preventable Emergency Department Visits
Potentially Avoidable Hospitalizati…
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www.ahrq.gov/news/newsroom/case-studies/cp30506.html
October 01, 2014 - AHRQ Resources Help Maine Telehealth Network Improve Care in Remote Areas
Search All Impact Case Studies
August 2005
A rural managed care program development project funded by AHRQ has helped create a thriving statewide collaborative telemedicine network. Maine Telehealth Network, in operation since 1998, h…
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psnet.ahrq.gov/issue/limits-psychological-safety-nonlinear-relationships-performance
April 24, 2018 - Study
The limits of psychological safety: nonlinear relationships with performance.
Citation Text:
Eldor L, Hodor M, Cappelli P. The limits of psychological safety: nonlinear relationships with performance. Org Behav Human Decision Proc. 2023;177:104255. doi:10.1016/j.obhdp.2023.104255. …
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psnet.ahrq.gov/issue/patients-politicians-cognitive-engineering-view-patient-safety
January 29, 2020 - Commentary
From patients to politicians: a cognitive engineering view of patient safety.
Citation Text:
Vicente KJ. From patients to politicians: a cognitive engineering view of patient safety. Qual Saf Health Care. 2002;11(4):302-4.
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psnet.ahrq.gov/issue/medical-malpractice-claims-members-uniformed-services
November 14, 2011 - Regulation
Medical malpractice claims by members of the uniformed services.
Citation Text:
Medical malpractice claims by members of the uniformed services. Department of Defense Office of General Counsel. 32 CFR Part 45. Fed Register. 86(115); June 17, 2021:32194-32215.
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psnet.ahrq.gov/issue/hospital-readmissions-physician-awareness-and-communication-practices
December 19, 2009 - Study
Classic
Hospital readmissions: physician awareness and communication practices.
Citation Text:
Roy CL, Kachalia A, Woolf S, et al. Hospital readmissions: physician awareness and communication practices. J Gen Intern Med. 2009;24(3):374-80. doi:10.1007/s1…
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psnet.ahrq.gov/issue/patient-safety-and-job-related-stress-focus-group-study
December 05, 2012 - Study
Patient safety and job-related stress: a focus group study.
Citation Text:
Berland A, Natvig GK, Gundersen D. Patient safety and job-related stress: A focus group study. Intensive and Critical Care Nursing. 2007;24(2). doi:10.1016/j.iccn.2007.11.001.
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psnet.ahrq.gov/issue/integrating-patient-safety-and-clinical-pharmacy-services-care-high-risk-ambulatory
April 08, 2020 - Study
Integrating patient safety and clinical pharmacy services into the care of a high-risk, ambulatory population: a collaborative approach.
Citation Text:
Robbins CM, Stillwell T, Johnson D, et al. Integrating Patient Safety and Clinical Pharmacy Services Into the Care of a High-Ris…