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psnet.ahrq.gov/issue/safety-culture-and-care-program-prevent-surgical-errors
March 25, 2020 - Commentary
Safety culture and care: a program to prevent surgical errors.
Citation Text:
Hemingway MW, O'Malley C, Silvestri S. Safety culture and care: a program to prevent surgical errors. AORN J. 2015;101(4):404-12; quiz 413-5. doi:10.1016/j.aorn.2015.01.002.
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psnet.ahrq.gov/issue/oncology-patients-willingness-report-their-medication-safety-concerns-home-qualitative-study
August 21, 2024 - Study
Oncology patients' willingness to report their medication safety concerns from home: a qualitative study.
Citation Text:
Bunni D, Walters G, Hwang M, et al. Oncology patients’ willingness to report their medication safety concerns from home: a qualitative study. Support Care Cancer…
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psnet.ahrq.gov/issue/tipping-point-relationship-between-volume-and-patient-harm
September 10, 2014 - Study
The tipping point: the relationship between volume and patient harm.
Citation Text:
Pedroja AT. The tipping point: the relationship between volume and patient harm. Am J Med Qual. 2008;23(5):336-41. doi:10.1177/1062860608320628.
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psnet.ahrq.gov/issue/factors-associated-emergency-department-visits-and-hospital-admissions-after-invasive
August 17, 2018 - Study
Factors associated with emergency department visits and hospital admissions after invasive outpatient procedures in the Veterans Health Administration.
Citation Text:
Mull HJ, Gellad ZF, Gupta RT, et al. Factors Associated With Emergency Department Visits and Hospital Admissions Af…
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www.ahrq.gov/sites/default/files/publications/files/system-design_0.pdf
July 01, 2011 - Designing Consumer Reporting Systems for Patient Safety Events: Project Overview
Advancing Excellence in Health Care • www.ahrq.gov
Agency for Healthcare Research and Quality PATIENT
SAFETY
Designing Consumer Reporting
Systems for Patient Safety Events
Background
It’s been nearly a decade since the Institute of
M…
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psnet.ahrq.gov/issue/establishing-multidisciplinary-taskforce-improve-anticoagulation-safety-large-health-system
July 08, 2020 - Commentary
Establishing a multidisciplinary taskforce to improve anticoagulation safety at a large health system.
Citation Text:
Attia E, Fuentes A, Vassallo M, et al. Establishing a multidisciplinary taskforce to improve anticoagulation safety at a large health system. Am J Health Syst …
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psnet.ahrq.gov/issue/ashp-guidelines-perioperative-pharmacy-services
December 21, 2014 - Review
ASHP guidelines on perioperative pharmacy services.
Citation Text:
Bickham P, Golembiewski J, Meyer T, et al. ASHP guidelines on perioperative pharmacy services. Am J Health Syst Pharm. 2019;76(12):903-820. doi:10.1093/ajhp/zxz073.
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psnet.ahrq.gov/issue/learning-accident-and-error-avoiding-hazards-workload-stress-and-routine-interruptions
September 27, 2023 - Commentary
Learning from accident and error: avoiding the hazards of workload, stress, and routine interruptions in the emergency department.
Citation Text:
Morrison B, Rudolph JW. Learning from accident and error: avoiding the hazards of workload, stress, and routine interruptions in th…
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psnet.ahrq.gov/issue/cost-implications-actual-and-potential-adverse-events-prevented-interventions-critical-care
June 28, 2010 - Study
Cost implications of actual and potential adverse events prevented by interventions of a critical care pharmacist.
Citation Text:
Kopp BJ, Mrsan M, Erstad BL, et al. Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist. Am J H…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/5-red-light-green-light.docx
June 01, 2023 - AHRQ Safety Program for Improving
Surgical Care and Recovery
Red Light, Green Light: An Overview of Common Implementation Barriers and Facilitators
Purpose of this tool: To help team leaders identify barriers to and facilitators of implementing Improving Surgical Care and Recovery (ISCR), an enhanced recovery program…
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psnet.ahrq.gov/issue/improving-weekend-out-hours-surgical-handover-woosh
May 27, 2011 - Commentary
Improving Weekend Out Of Hours Surgical Handover (WOOSH).
Citation Text:
Boyer M, Tappenden J, Peter M. Improving Weekend Out Of hours Surgical Handover (WOOSH). BMJ Qual Improv Rep. 2016;5(1):1-4. doi:10.1136/bmjquality.u209552.w4190.
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psnet.ahrq.gov/issue/failure-recognize-newly-identified-aortic-dilations-health-care-system-advanced-electronic
August 04, 2021 - Study
Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record.
Citation Text:
Gordon JRS, Wahls TL, Carlos RC, et al. Failure to recognize newly identified aortic dilations in a health care system with an advanced electro…
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psnet.ahrq.gov/issue/evaluation-frequency-dispensing-electronically-discontinued-medications-and-associated
March 03, 2019 - Study
Evaluation of the frequency of dispensing electronically discontinued medications and associated outcomes.
Citation Text:
Copi EJ, Kelley LR, Fisher KK. Evaluation of the frequency of dispensing electronically discontinued medications and associated outcomes. J Am Pharm Assoc (2003…
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psnet.ahrq.gov/issue/electronic-health-record-use-and-quality-ambulatory-care-united-states
May 31, 2023 - Study
Electronic health record use and the quality of ambulatory care in the United States.
Citation Text:
Linder JA, Ma J, Bates DW, et al. Electronic health record use and the quality of ambulatory care in the United States. Arch Intern Med. 2007;167(13):1400-5.
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psnet.ahrq.gov/issue/hhs-seeks-input-medical-office-survey-patient-safety-culture-database-information-collection
March 13, 2024 - Press Release/Announcement
HHS seeks input on Medical Office Survey on Patient Safety Culture Database information collection.
Citation Text:
HHS seeks input on Medical Office Survey on Patient Safety Culture Database information collection. Agency for Healthcare Quality and Research. Fe…
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psnet.ahrq.gov/issue/consensus-building-development-outpatient-adverse-drug-event-triggers
November 10, 2010 - Study
Consensus building for development of outpatient adverse drug event triggers.
Citation Text:
Mull HJ, Nebeker JR, Shimada SL, et al. Consensus building for development of outpatient adverse drug event triggers. J Patient Saf. 2011;7(2):66-71. doi:10.1097/PTS.0b013e31820c98ba.
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psnet.ahrq.gov/issue/evaluation-detected-medication-errors-within-operating-room-academic-medical-center
October 19, 2022 - Study
Evaluation of detected medication errors within the operating room at an academic medical center.
Citation Text:
Wolf M, Rolf J, Nelson D, et al. Evaluation of detected medication errors within the operating room at an academic medical center. Hosp Pharm. 2023;58(3):309-314. doi:10…
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psnet.ahrq.gov/issue/unrecognized-cardiovascular-emergencies-among-medicare-patients
November 16, 2022 - Study
Unrecognized cardiovascular emergencies among Medicare patients.
Citation Text:
Waxman DA, Kanzaria HK, Schriger DL. Unrecognized Cardiovascular Emergencies Among Medicare Patients. JAMA Intern Med. 2018;178(4):477-484. doi:10.1001/jamainternmed.2017.8628.
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psnet.ahrq.gov/issue/see-one-sim-one-do-one-national-pre-internship-boot-camp-ensure-safer-student-doctor
February 16, 2011 - Study
"See One, Sim One, Do One"—a national pre-internship boot-camp to ensure a safer "student to doctor" transition.
Citation Text:
Minha S'ar, Shefet D, Sagi D, et al. "See One, Sim One, Do One"- A National Pre-Internship Boot-Camp to Ensure a Safer "Student to Doctor" Transition. PLo…
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psnet.ahrq.gov/issue/patient-perceptions-misdiagnosis-endometriosis-results-online-national-survey
February 05, 2020 - Study
Patient perceptions of misdiagnosis of endometriosis: results from an online national survey.
Citation Text:
Bontempo AC, Mikesell L. Patient perceptions of misdiagnosis of endometriosis: results from an online national survey. Diagnosis (Berl). 2020;7(2):97-106. doi:10.1515/dx-201…