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psnet.ahrq.gov/issue/application-failure-mode-effect-analysis-improve-care-septic-patients-admitted-through
February 01, 2013 - Study
Application of failure mode effect analysis to improve the care of septic patients admitted through the emergency department.
Citation Text:
Alamry A, Owais SMA, Marini AM, et al. Application of Failure Mode Effect Analysis to Improve the Care of Septic Patients Admitted Through th…
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psnet.ahrq.gov/issue/improvement-patient-safety-may-precede-policy-changes-trends-patient-safety-indicators-united
November 01, 2017 - Study
Improvement in patient safety may precede policy changes: trends in patient safety indicators in the United States, 2000-2013.
Citation Text:
Tedesco D, Moghavem N, Weng Y, et al. Improvement in patient safety may precede policy changes: trends in patient safety indicators in the U…
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digital.ahrq.gov/ahrq-funded-projects/automating-assessment-obesity-care-quality/annual-summary/2012
January 01, 2012 - Automating Assessment of Obesity Care Quality - 2012
Project Name
Automating Assessment of Obesity Care Quality
Principal Investigator
Hazlehurst, Brian L.
Organization
Kaiser Foundation Research Institute
Funding Mechanism
PAR: HS08-270: Utilizing Health IT to Impr…
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digital.ahrq.gov/ahrq-funded-projects/past-initiatives/state-and-regional-demonstration-projects/utah
January 01, 2023 - Utah
Project Overview | Data and Functionality | Technical Design and Architecture
Project Overview
The Utah Health Information Network (UHIN) is a broad-based coalition of health care insurers, providers, and other interested parties, including State government. UHIN participant…
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psnet.ahrq.gov/issue/problem-root-cause-analysis
August 28, 2024 - Commentary
The problem with root cause analysis.
Citation Text:
Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417-422. doi:10.1136/bmjqs-2016-005511.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML…
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psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events
April 17, 2024 - Study
Putting the "action" in RCA(2): an analysis of intervention strength after adverse events.
Citation Text:
Zerillo JA, Tardiff SA, Flood D, et al. Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Jt Comm J Qual Patient Saf. 2024;50(7):492-49…
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psnet.ahrq.gov/issue/experiences-nurses-speaking-healthcare-settings-qualitative-metasynthesis
September 23, 2020 - Review
Experiences of nurses speaking up in healthcare settings: a qualitative metasynthesis.
Citation Text:
Lee E, De Gagne J C, Randall P S, et al. Experiences of nurses speaking up in healthcare settings: a qualitative metasynthesis. J Adv Nurs. 2024;Epub Nov 4. doi:10.1111/jan.16592.…
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psnet.ahrq.gov/issue/open-disclosure-among-general-practitioners-second-victim-patient-safety-incident-cross
February 15, 2023 - Study
Open disclosure among general practitioners as second victim of a patient safety incident: a cross-sectional study in Flanders (Belgium).
Citation Text:
Neyens L, Stouten E, Vanhaecht K, et al. Open disclosure among general practitioners as second victim of a patient safety inciden…
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cdsic.ahrq.gov/sites/default/files/2023-02/Real%20World%20PC%20CDS_Patient-Centered%20CDS%20for%20Postpartum%20Hypertension%20Monitoring_508_Jan26.pdf
January 01, 2023 - Patient-Centered CDS for Postpartum Hypertension Monitoring
Patient-Centered CDS for Postpartum Hypertension Monitoring
At age 42, Brittany McFarland was excited about her first pregnancy after over a year of trying to conceive. All was going well
with the pregnancy until she developed preeclampsia in her third…
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psnet.ahrq.gov/issue/adopting-fall-tailoring-interventions-patient-safety-tips-program-engage-older-adults-fall
December 08, 2021 - Commentary
Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention in a nursing home.
Citation Text:
Tzeng H-M, Jansen LS, Okpalauwaekwe U, et al. Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to …
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psnet.ahrq.gov/issue/nurse-leader-perspectives-and-experiences-caregiver-support-following-serious-medical-error
March 06, 2024 - Study
Nurse leader perspectives and experiences on caregiver support following a serious medical error.
Citation Text:
Prothero MM, Sorhus M, Huefner K. Nurse leader perspectives and experiences on caregiver support following a serious medical error. J Nurs Adm. 2024;54(12):664-669. doi:…
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digital.ahrq.gov/health-care-theme/chronic-disease-management
January 01, 2023 - Chronic Disease Management
Patient Intestinal Failure-ECHO Project (PIF-ECHO)
Description
This study will evaluate the feasibility and effectiveness of providing chronic intestinal failure patients and their family caregivers with direct access to live, virtual, multi-discipli…
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psnet.ahrq.gov/issue/factors-impacting-patient-setup-analysis-and-error-management-during-breast-cancer
September 15, 2021 - Review
Factors impacting on patient setup analysis and error management during breast cancer radiotherapy.
Citation Text:
Costin I-C, Marcu LG. Factors impacting on patient setup analysis and error management during breast cancer radiotherapy. Crit Rev Oncol Hematol. 2022;178:103798. doi…
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psnet.ahrq.gov/issue/choosing-your-words-carefully-how-physicians-would-disclose-harmful-medical-errors-patients
February 16, 2011 - Study
Classic
Choosing your words carefully: how physicians would disclose harmful medical errors to patients.
Citation Text:
Gallagher TH, Garbutt J, Waterman AD, et al. Choosing your words carefully: how physicians would disclose harmful medical errors to pa…
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psnet.ahrq.gov/issue/nurse-burnout-and-patient-safety-satisfaction-and-quality-care-systematic-review-and-meta
November 18, 2016 - Review
Nurse burnout and patient safety, satisfaction, and quality of care: a systematic review and meta-analysis.
Citation Text:
Li LZ, Yang P, Singer SJ, et al. Nurse burnout and patient safety, satisfaction, and quality of care: a systematic review and meta-analysis. JAMA Netw Open. 2…
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psnet.ahrq.gov/issue/effects-efforts-optimise-morbidity-and-mortality-rounds-serve-contemporary-quality
July 19, 2019 - Review
Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and educational goals: a systematic review.
Citation Text:
Smaggus A, Mrkobrada M, Marson A, et al. Effects of efforts to optimise morbidity and mortality rounds to serve contem…
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psnet.ahrq.gov/issue/accuracy-patient-understanding-common-medical-phrases
November 30, 2022 - Study
Accuracy in patient understanding of common medical phrases.
Citation Text:
Gotlieb R, Praska C, Hendrickson MA, et al. Accuracy in patient understanding of common medical phrases. JAMA Netw Open. 2022;5(11):e2242972. doi:10.1001/jamanetworkopen.2022.42972.
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psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-preventable-complications
January 22, 2014 - Commentary
Classic
The wisdom and justice of not paying for "preventable complications."
Citation Text:
Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.1…
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www.ahrq.gov/news/newsroom/case-studies/cquips0802.html
October 01, 2014 - AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors in Emergency Departments
Search All Impact Case Studies
June 2008
AHRQ-sponsored research on how clinical pharmacy services can reduce medication-related errors in hospital emergency departments has been put to use in hospitals in a …
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psnet.ahrq.gov/issue/parents-understanding-medication-discharge-and-potential-harm-children-medical-complexity
April 22, 2020 - Study
Parents' understanding of medication at discharge and potential harm in children with medical complexity.
Citation Text:
Selzer A, Eibensteiner F, Kaltenegger L, et al. Parents’ understanding of medication at discharge and potential harm in children with medical complexity. Arch Di…