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psnet.ahrq.gov/issue/effect-automated-unit-dose-dispensing-barcode-scanning-medication-administration-errors
August 10, 2022 - Study
Effect of automated unit dose dispensing with barcode scanning on medication administration errors: an uncontrolled before-and-after study.
Citation Text:
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Effect of automated unit dose dispensing with barcode scanning on medication a…
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psnet.ahrq.gov/issue/using-inpatient-portal-engage-families-pediatric-hospital-care
September 13, 2023 - Study
Using an inpatient portal to engage families in pediatric hospital care.
Citation Text:
Kelly MM, Hoonakker P, Dean SM. Using an inpatient portal to engage families in pediatric hospital care. J Am Med Inform Assoc. 2017;24(1):153-161. doi:10.1093/jamia/ocw070.
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psnet.ahrq.gov/issue/new-problems-and-iatrogenic-events-among-older-adults-first-30-days-post-acute-rehabilitation
March 16, 2022 - Study
New problems and iatrogenic events among older adults in the first 30 days of post-acute rehabilitation.
Citation Text:
Simpson M, Kovach CR. New problems and iatrogenic events among older adults in the first 30 days of post-acute rehabilitation. Res Gerontol Nurs. 2021;14(6):293-3…
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psnet.ahrq.gov/issue/situ-simulation-program-quantitative-and-qualitative-prospective-study-identifying-latent
March 25, 2021 - Study
An in situ simulation program: a quantitative and qualitative prospective study identifying latent safety threats and examining participant experiences.
Citation Text:
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. An in situ simulation program: a quantitative and qualitativ…
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psnet.ahrq.gov/issue/meta-analysis-effectiveness-crew-resource-management-training-acute-care-domains
July 24, 2013 - Review
A meta-analysis of the effectiveness of crew resource management training in acute care domains.
Citation Text:
O'Dea A, O'Connor P, Keogh I. A meta-analysis of the effectiveness of crew resource management training in acute care domains. Postgrad Med J. 2014;90(1070):699-708. doi…
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psnet.ahrq.gov/issue/interventions-reduce-medication-dispensing-administration-and-monitoring-errors-pediatric
June 23, 2021 - Review
Interventions to reduce medication dispensing, administration, and monitoring errors in pediatric professional healthcare settings: a systematic review.
Citation Text:
Koeck JA, Young NJ, Kontny U, et al. Interventions to reduce medication dispensing, administration, and monitorin…
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psnet.ahrq.gov/issue/patient-safety-over-power-hierarchy-scoping-review-healthcare-professionals-speaking-skills
November 11, 2009 - Review
Emerging Classic
Patient safety over power hierarchy: a scoping review of healthcare professionals' speaking-up skills training.
Citation Text:
Kim S, Appelbaum NP, Baker N, et al. Patient Safety Over Power Hierarchy: A Scoping Review of Healthcare Profes…
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psnet.ahrq.gov/issue/risk-factors-adverse-events-emergency-department-procedural-sedation-children
January 19, 2014 - Study
Risk factors for adverse events in emergency department procedural sedation for children.
Citation Text:
Bhatt M, Johnson DW, Chan J, et al. Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children. JAMA Pediatr. 2017;171(10):957-964. doi:10.1001/jam…
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psnet.ahrq.gov/issue/impact-missed-nursing-care-or-care-not-done-adults-health-care-rapid-review-consensus
October 27, 2021 - Review
The impact of "missed nursing care" or "care not done" on adults in health care: a rapid review for the Consensus Development Project.
Citation Text:
Willis E, Brady C. The impact of “missed nursing care” or “care not done” on adults in health care: A rapid review for the Consensu…
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psnet.ahrq.gov/issue/medication-dispensing-errors-and-potential-adverse-drug-events-and-after-implementing-bar
June 28, 2010 - Study
Classic
Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy.
Citation Text:
Poon EG, Cina J, Churchill WW, et al. Medication dispensing errors and potential adverse drug events …
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digital.ahrq.gov/sites/default/files/docs/page/Utah%204-VI.ppt
June 16, 2021 - Medication History Settings
Utah Health Information Network
Evaluation Method Summary
AHRQ 2006
Jan Root, Ph.D.
Assistant Executive Director
UHIN Pilot
Submitter Receiver Message Format
Hospital Providers (clinical messages)
Payers (claim attachments) Discharge summaries, etc. HL7, pdf
Clinics Hospitals (clinic…
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psnet.ahrq.gov/issue/covid-19-emerging-threat-antibiotic-stewardship-emergency-department
October 21, 2020 - Commentary
COVID-19: an emerging threat to antibiotic stewardship in the emergency department.
Citation Text:
Pulia M, Wolf I, Schulz L, et al. COVID-19: an emerging threat to antibiotic stewardship in the emergency department. West J Emerg Med. 2020;21(5):1283-1286. doi:10.5811/westjem.…
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psnet.ahrq.gov/issue/understanding-principles-high-reliability-organizations-through-eyes-vione-clinical-program
November 15, 2023 - Study
Understanding principles of high reliability organizations through the eyes of VIONE: a clinical program to improve patient safety by deprescribing potentially inappropriate medications and reducing polypharmacy.
Citation Text:
Battar S, Dickerson KRW, Sedgwick C, et al. Understand…
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psnet.ahrq.gov/issue/good-bad-and-ugly-operative-staff-perspectives-surgeon-coping-intraoperative-errors
September 22, 2021 - Study
The good, the bad, and the ugly: operative staff perspectives of surgeon coping with intraoperative errors.
Citation Text:
D’Angelo A-LD, Kapur N, Kelley SR, et al. The good, the bad, and the ugly: operative staff perspectives of surgeon coping with intraoperative errors. Surgery. …
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psnet.ahrq.gov/issue/supporting-nursing-midwifery-and-allied-health-professional-students-raise-concerns-quality
November 26, 2014 - Review
Supporting nursing, midwifery and allied health professional students to raise concerns with the quality of care: a review of the research literature.
Citation Text:
Milligan F, Wareing M, Preston-Shoot M, et al. "Supporting nursing, midwifery and allied health professional studen…
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psnet.ahrq.gov/issue/using-behavioral-insights-strengthen-strategies-change-practical-applications-quality
April 06, 2022 - Commentary
Using behavioral insights to strengthen strategies for change. Practical applications for quality improvement in healthcare.
Citation Text:
Johansen RLR, Tulloch S. Using behavioral insights to strengthen strategies for change. Practical applications for quality improvement in…
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psnet.ahrq.gov/issue/economic-measurement-medical-errors
March 23, 2022 - Book/Report
The Economic Measurement of Medical Errors.
Citation Text:
The Economic Measurement of Medical Errors. Shreve J, van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. Schaumburg, IL: The Society of Actuaries; 2010.
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psnet.ahrq.gov/issue/you-can-campaign-teamwork-training-patients-and-families-ambulatory-oncology
September 01, 2016 - Study
The You CAN campaign: teamwork training for patients and families in ambulatory oncology.
Citation Text:
Weingart SN, Simchowitz B, Eng TK, et al. The You CAN campaign: teamwork training for patients and families in ambulatory oncology. Jt Comm J Qual Patient Saf. 2009;35(2):63-71.…
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psnet.ahrq.gov/issue/mortality-and-risk-factors-associated-misdiagnosis-acute-aortic-syndrome-ontario-canada
September 23, 2020 - Study
Mortality and risk factors associated with misdiagnosis of acute aortic syndrome in Ontario, Canada: a population-based study.
Citation Text:
Ohle R, Savage DW, Caswell J, et al. Mortality and risk factors associated with misdiagnosis of acute aortic syndrome in Ontario, Canada: a …
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psnet.ahrq.gov/issue/what-are-safety-risks-patients-undergoing-treatment-multiple-specialties-retrospective
March 18, 2013 - Study
What are the safety risks for patients undergoing treatment by multiple specialties: a retrospective patient record review study.
Citation Text:
Baines RJ, de Bruijne M, Langelaan M, et al. What are the safety risks for patients undergoing treatment by multiple specialties: a retr…