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psnet.ahrq.gov/node/47754/psn-pdf
April 17, 2019 - FDA identifies harm reported from sudden
discontinuation of opioid pain medicines and requires
label changes to guide prescribers on gradual,
individualized tapering.
April 17, 2019
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
https://psnet.ahrq.gov/issue/fda-identifies-harm-reported-sudden-…
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psnet.ahrq.gov/node/45335/psn-pdf
August 10, 2016 - The Feasibility of Determining the Effectiveness and Cost-
effectiveness of Medication Organisation Devices
Compared with Usual Care for Older People in a
Community Setting: Systematic Review, Stakeholder
Focus Groups and Feasibility RCT.
August 10, 2016
Bhattacharya D, Aldus CF, Barton G, et al. Health Tech…
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psnet.ahrq.gov/node/60966/psn-pdf
January 01, 2021 - Expanding frontiers of risk management: care safety in
nursing home during COVID-19 pandemic.
September 30, 2020
Scopetti M, Santurro A, Tartaglia R, et al. Expanding frontiers of risk management: care safety in nursing
home during COVID-19 pandemic. Int J Qual Health Care. 2021;33(1):mzaa085.
doi:10.1093/intqhc/m…
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psnet.ahrq.gov/node/73443/psn-pdf
June 30, 2021 - Impact of technological and departmental changes on
incident rates in radiation oncology over a seventeen-year
period.
June 30, 2021
Le Cornu E, Murray S, Brown EJ, et al. Impact of technological and departmental changes on incident rates
in radiation oncology over a seventeen?year period. J Med Radiat Sci. 2021;6…
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www.ahrq.gov/talkingquality/translate/scores/index.html
March 01, 2016 - Generating Health Care Quality Scores That Show Differences
The critical link between collecting performance information and sharing that information with others is the process of generating scores. The nature of the score is often inherent in the measure (e.g., an overall rating on a 1-10 scale). But even in…
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psnet.ahrq.gov/node/74152/psn-pdf
December 08, 2021 - Adverse events and their contributors among older adults
during skilled nursing stays for rehabilitation: a scoping
review.
December 8, 2021
Okpalauwaekwe U, Tzeng H-M. Adverse events and their contributors among older adults during skilled
nursing stays for rehabilitation: a scoping review. Patient Relat Outcome …
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psnet.ahrq.gov/node/36348/psn-pdf
March 09, 2009 - Reducing medical error in the Military Health System: how
can team training help?
March 9, 2009
Alonso A, Baker DP, Holtzman A, et al. Reducing medical error in the Military Health System: How can
team training help? Human Resource Management Review. 2006;16(3). doi:10.1016/j.hrmr.2006.05.006.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/45192/psn-pdf
December 04, 2016 - Evidence summary and recommendations for improved
communication during care transitions.
December 4, 2016
Jackson PD, Biggins MS, Cowan L, et al. Evidence Summary and Recommendations for Improved
Communication during Care Transitions. Rehabil Nurs. 2016;41(3):135-48. doi:10.1002/rnj.230.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/46133/psn-pdf
May 24, 2017 - Implementing smart infusion pumps with dose-error
reduction software: real-world experiences.
May 24, 2017
Heron C. Implementing smart infusion pumps with dose-error reduction software: real-world experiences.
Br J Nurs. 2017;26(8):S13-S16. doi:10.12968/bjon.2017.26.8.S13.
https://psnet.ahrq.gov/issue/implementing…
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psnet.ahrq.gov/node/859343/psn-pdf
December 20, 2023 - Reducing retained foreign objects in the operating room:
a quality improvement initiative.
December 20, 2023
Keane OA, Chambers C, Brady CM, et al. Reducing retained foreign objects in the operating room: a
quality improvement initiative. J Am Coll Surg. 2023;237(6):864-872. doi:10.1097/xcs.0000000000000847.
https…
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psnet.ahrq.gov/node/43595/psn-pdf
November 19, 2014 - Patient safety in external beam radiotherapy—guidelines
on risk assessment and analysis of adverse error-events
and near misses: introducing the ACCIRAD project.
November 19, 2014
Malicki J, Bly R, Bulot M, et al. Patient safety in external beam radiotherapy - guidelines on risk
assessment and analysis of adverse …
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psnet.ahrq.gov/node/34889/psn-pdf
March 04, 2011 - Effect of electronic health records in ambulatory care:
retrospective, serial, cross sectional study.
March 4, 2011
Garrido T, Jamieson L, Zhou Y, et al. Effect of electronic health records in ambulatory care: retrospective,
serial, cross sectional study. BMJ. 2005;330(7491):581.
https://psnet.ahrq.gov/issue/effec…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/improve/teams-infographic.html
March 01, 2017 - T.E.A.M.S. infographic
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Culture consists of values, attitudes, and beliefs that can have an impact on resident safety, care outcomes, and staff satisfaction.
Culture influences how change can occur.
T
Team Formation
The most effective…
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psnet.ahrq.gov/node/864370/psn-pdf
March 13, 2024 - How do patients and care partners describe diagnostic
uncertainty in an emergency department or urgent care
setting?
March 13, 2024
DeGennaro AP, Gonzalez N, Peterson SM, et al. How do patients and care partners describe diagnostic
uncertainty in an emergency department or urgent care setting? Diagnosis (Berl). 20…
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psnet.ahrq.gov/node/72851/psn-pdf
March 17, 2021 - Effect of a multifaceted clinical pharmacist intervention
on medication safety after hospitalization in persons
prescribed high-risk medications: a randomized clinical
trial.
March 17, 2021
Gurwitz JH, Kapoor A, Garber L, et al. Effect of a multifaceted clinical pharmacist intervention on
medication safety after …
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psnet.ahrq.gov/node/35877/psn-pdf
July 23, 2010 - National Quality Forum 30 safe practices: priority and
progress in Iowa hospitals.
July 23, 2010
Ward MM, Evans TC, Spies AJ, et al. National Quality Forum 30 safe practices: priority and progress in
Iowa hospitals. Am J Med Qual. 2006;21(2):101-8.
https://psnet.ahrq.gov/issue/national-quality-forum-30-safe-practi…
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psnet.ahrq.gov/node/46103/psn-pdf
September 23, 2017 - Polypharmacy in the elderly--when good drugs lead to
bad outcomes: a teachable moment.
September 23, 2017
Carroll C, Hassanin A. Polypharmacy in the Elderly-When Good Drugs Lead to Bad Outcomes: A
Teachable Moment. JAMA Intern Med. 2017;177(6):871. doi:10.1001/jamainternmed.2017.0911.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/73466/psn-pdf
July 07, 2021 - COVID-19 and open notes: a new method to enhance
patient safety and trust.
July 7, 2021
Blease CR, Salmi L, Hägglund M, et al. COVID-19 and open notes: a new method to enhance patient
safety and trust. JMIR Ment Health. 2021;8(6):e29314. doi:10.2196/29314.
https://psnet.ahrq.gov/issue/covid-19-and-open-notes-new-m…
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www.ahrq.gov/research/findings/final-reports/iomracereport/reldata1fig1-2.html
April 01, 2018 - Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement
Figure 1-2. Williams, Lavizzo-Mourey, and Warren's framework for understanding the relationships between race, medical/health care, and health
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Table of Contents
Race, Ethnicity, and Langua…
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www.ahrq.gov/research/findings/final-reports/iomracereport/reldata4fig4-2.html
May 01, 2018 - Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement
Figure 4-2: Karliner algorithm
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Table of Contents
Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement
Summary
Reviewers
1. Introduction
2. Eviden…