-
digital.ahrq.gov/developing-and-testing-quality-measures-interoperable-electronic-health-records
January 01, 2023 - Developing and Testing Quality Measures for Interoperable Electronic Health Records
Your browser does not support inline frames. Please go to https://youtu.be/-0H1ENHAFew to view the video. Principal Investigator: Rainu Kaushal (Grant No. R18 HS017067) [6 min., 51 sec.] The story features …
-
digital.ahrq.gov/ahrq-funded-projects/surveillance-adverse-drug-events-ambulatory-pediatrics/citation/informatics
January 01, 2023 - The informatics opportunities at the intersection of patient safety and clinical informatics.
Citation
Kilbridge PM, Classen DC. The informatics opportunities at the intersection of patient safety and clinical informatics. J Am Med Inform Assoc 2008 Jul-Aug;15(4):397-407.
Link
Kilbridge PM, Cl…
-
psnet.ahrq.gov/node/41520/psn-pdf
December 12, 2012 - Information distortion in physicians' diagnostic
judgments.
December 12, 2012
Kostopoulou O, Russo E, Keenan G, et al. Information distortion in physicians' diagnostic judgments. Med
Decis Making. 2012;32(6):831-9. doi:10.1177/0272989X12447241.
https://psnet.ahrq.gov/issue/information-distortion-physicians-diagnos…
-
psnet.ahrq.gov/node/35699/psn-pdf
November 18, 2011 - Improving the Reliability of Health Care.
November 18, 2011
Nolan T, Resar R, Haraden C, et al. Boston, MA: Institute for Healthcare Improvement; 2004.
https://psnet.ahrq.gov/issue/improving-reliability-health-care
This report shares a three-step model for applying reliability principles to health care. The element…
-
psnet.ahrq.gov/node/36031/psn-pdf
June 21, 2006 - Patient safety, systems design and ergonomics.
June 21, 2006
Buckle P, Clarkson PJ, Coleman R, et al. Patient safety, systems design and ergonomics. Appl Ergon.
2006;37(4):491-500. doi:10.1016/j.apergo.2006.04.016.
https://psnet.ahrq.gov/issue/patient-safety-systems-design-and-ergonomics
The authors discuss design…
-
psnet.ahrq.gov/node/36253/psn-pdf
November 28, 2018 - Medication Reconciliation Handbook, 2nd edition.
November 28, 2018
American Society of Health-System Pharmacists, Joint Commission on Accreditation of Healthcare
Organizations. Oakbrook Terrace IL; Joint Commission Resources: 2009. ISBN 9781599403090.
https://psnet.ahrq.gov/issue/medication-reconciliation-handbook-…
-
psnet.ahrq.gov/node/42646/psn-pdf
October 23, 2013 - System-related factors contributing to diagnostic errors.
October 23, 2013
Thammasitboon S, Thammasitboon S, Singhal G. System-related factors contributing to diagnostic errors.
Curr Probl Pediatr Adolesc Health Care. 2013;43(9):242-7. doi:10.1016/j.cppeds.2013.07.004.
https://psnet.ahrq.gov/issue/system-related-fa…
-
psnet.ahrq.gov/node/37611/psn-pdf
February 15, 2011 - SBAR for patients.
February 15, 2011
Denham CR. SBAR for Patients. J Patient Saf. 2008;4(1). doi:10.1097/pts.0b013e2181660c06.
https://psnet.ahrq.gov/issue/sbar-patients
This commentary presents information and background on the standardized communication process known
as SBAR (situation, background, assessment, a…
-
psnet.ahrq.gov/node/34911/psn-pdf
April 21, 2005 - Patient Safety Essentials for Health Care. 5th ed.
April 21, 2005
Oakbrook Terrace, IL: Joint Commission Resources; 2009.
https://psnet.ahrq.gov/issue/4th-ed-patient-safety-essentials-health-care
This book provides a complete overview of the Joint Commission's National Patient Safety Goals and how
to apply them in…
-
psnet.ahrq.gov/node/39961/psn-pdf
March 08, 2015 - When errors occur.
March 8, 2015
Wetzel TG. When errors occur, 'I'm sorry' is a big step, but just the first. Hospitals & health networks.
2010;84(10):41-2, 44, 2.
https://psnet.ahrq.gov/issue/when-errors-occur
This article describes how hospital responses to adverse events have affected disclosure process
strate…
-
psnet.ahrq.gov/node/39224/psn-pdf
August 11, 2015 - Diagnostic error and clinical reasoning.
August 11, 2015
Norman GR, Eva KW. Diagnostic error and clinical reasoning. Med Educ. 2010;44(1):94-100.
doi:10.1111/j.1365-2923.2009.03507.x.
https://psnet.ahrq.gov/issue/diagnostic-error-and-clinical-reasoning
This article reviews evidence on the cognitive origins of diag…
-
psnet.ahrq.gov/node/37284/psn-pdf
December 30, 2014 - Medication tracers: a systems approach to medication
safety.
December 30, 2014
Hendrick EC, Montanya KR, Griffith NL. Medication Tracers: A Systems Approach to Medication Safety.
Hosp Pharm. 2010;42(10):916-920. doi:10.1310/hpj4210-916.
https://psnet.ahrq.gov/issue/medication-tracers-systems-approach-medication-sa…
-
psnet.ahrq.gov/node/36941/psn-pdf
July 19, 2017 - ACOG Committee Opinion #508: disruptive behavior.
July 19, 2017
ACOG Committee Opinion No. 508: disruptive behavior. Obstet Gynecol. 2011;118(4):970-2.
doi:10.1097/AOG.0b013e3182358acc.
https://psnet.ahrq.gov/issue/acog-committee-opinion-508-disruptive-behavior
This guideline outlines important areas of concern an…
-
psnet.ahrq.gov/node/38092/psn-pdf
September 24, 2008 - Time out: an analysis.
September 24, 2008
Dillon KA. Time out: an analysis. AORN J. 2008;88(3):437-442. doi:10.1016/j.aorn.2008.03.003.
https://psnet.ahrq.gov/issue/time-out-analysis
This article discusses the reasons for utilizing the Joint Commission Universal Protocol for time outs and
describes a process for i…
-
www.ahrq.gov/news/rfi-diagnostic-excellence.html
February 01, 2025 - AHRQ Seeks Input on Measures of Diagnostic Excellence
A Request for Informatio n published by AHRQ requests public comments by March 10 on the development of measures of diagnostic excellence that may be calculated using administrative data or electronic health record data. The purpose of diagnostic excellence…
-
psnet.ahrq.gov/node/38911/psn-pdf
September 09, 2009 - Radiology failure mode and effect analysis: what is it?
September 9, 2009
Abujudeh H, Kaewlai R. Radiology failure mode and effect analysis: what is it? Radiology.
2009;252(2):544-50. doi:10.1148/radiol.2522081954.
https://psnet.ahrq.gov/issue/radiology-failure-mode-and-effect-analysis-what-it
This article introdu…
-
digital.ahrq.gov/sites/default/files/docs/citation/u18hs027557-dykes-final-report-2022.pdf
January 01, 2022 - current-state fall prevention practices in clinics so that we
may identify the gaps and needs in those processes … virtual workflow
observation where the provider would demonstrate the activities, steps, and thought processes … Additionally, if manual processes exist in
addition to automated functions with the CDS, time can be
-
digital.ahrq.gov/sites/default/files/docs/citation/r21hs027248-kowalkowski-final-report-2023.pdf
January 01, 2023 - session to engage end users (patients, caregivers, and
providers) early in app ideation and development processes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
April 09, 2004 - New
systems or processes can be implemented and measured to determine their
effectiveness for reducing
-
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-31-facilitating-panel-management.pdf
September 01, 2015 - Processes need to be established in the practice to ensure the sustainability of managing patient
panels … For example, training materials and job descriptions need to be established with
panel management processes