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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38507/psn-pdf
    February 10, 2015 - From tasks to processes: the case for changing health information technology to improve health care. February 10, 2015 Walker JM, Carayon P. From tasks to processes: the case for changing health information technology to improve health care. Health Aff (Millwood). 2009;28(2):467-477. doi:10.1377/hlthaff.28.2.467. …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36495/psn-pdf
    May 11, 2014 - Improving safety throughout the medication use process in a neonatal intensive care unit. May 11, 2014 Asdigha MN. Improving Safety Throughout the Medication Use Process in a Neonatal Intensive Care Unit. Hosp Pharm. 2010;41(11):1067-1075. doi:10.1310/hpj4111-1067. https://psnet.ahrq.gov/issue/improving-safety-thr…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38869/psn-pdf
    August 19, 2009 - Frequency and severity of harm of medication errors related to the parenteral nutrition process in a large university teaching hospital. August 19, 2009 Sacks GS, Rough S, Kudsk KA. Frequency and severity of harm of medication errors related to the parenteral nutrition process in a large university teaching hospit…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36362/psn-pdf
    October 27, 2010 - Effectiveness of Toyota process redesign in reducing thyroid gland fine-needle aspiration error. October 27, 2010 Raab SS, Grzybicki DM, Sudilovsky D, et al. Effectiveness of Toyota process redesign in reducing thyroid gland fine-needle aspiration error. Am J Clin Pathol. 2006;126(4):585-92. https://psnet.ahrq.gov…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39369/psn-pdf
    March 17, 2010 - Paediatric nurses' understanding of the process and procedure of double-checking medications. March 17, 2010 Dickinson A, McCall E, Twomey B, et al. Paediatric nurses' understanding of the process and procedure of double-checking medications. J Clin Nurs. 2010;19(5-6). doi:10.1111/j.1365-2702.2009.03130.x. https:/…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39516/psn-pdf
    June 27, 2011 - Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units. June 27, 2011 De Giorgi I, Fonzo-Christe C, Cingria L, et al. Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units. Int…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42306/psn-pdf
    May 29, 2013 - Do team processes really have an effect on clinical performance? A systematic literature review. May 29, 2013 Schmutz J, Manser T. Do team processes really have an effect on clinical performance? A systematic literature review. Br J Anaesth. 2013;110(4). doi:10.1093/bja/aes513. https://psnet.ahrq.gov/issue/do-team…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40747/psn-pdf
    September 07, 2011 - Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes. September 7, 2011 Neale G, Hogan H, Sevdalis N. Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes. Clin Med (Lond). 2011;11(4):317-321. https://psnet.ahrq.g…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39296/psn-pdf
    January 22, 2017 - Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. January 22, 2017 Aboumatar HJ, Winner L, Davis RO, et al. Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. Jt Comm J Qual Patient Saf. 2010;36(2):79-86. https://psnet.ahrq.gov/issue/applying-lea…
  10. www.ahrq.gov/sites/default/files/2025-02/silver2-report.pdf
    January 01, 2025 - Final Progress Report: Sociotechnical Probabilistic Risk Assessment in Home Health Care ST-PRA IN HOME HEALTH CARE Title: Sociotechnical Probabilistic Risk Assessment in Home Health Care Principal Investigator and Team Members: Michael P. Silver, MPH Principal Investigator Cher Edmonds, Study Coordinator Robert Fer…
  11. psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Andrew P.J. …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38621/psn-pdf
    February 18, 2011 - Process of care failures in breast cancer diagnosis. February 18, 2011 Weingart SN, Saadeh MG, Simchowitz B, et al. Process of care failures in breast cancer diagnosis. J Gen Intern Med. 2009;24(6):702-709. doi:10.1007/s11606-009-0982-0. https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis Di…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47045/psn-pdf
    January 21, 2019 - Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study. January 21, 2019 Arbaje AI, Hughes A, Werner N, et al. Information management goals and process failures during …
  14. effectivehealthcare.ahrq.gov/sites/default/files/module-ii-stakeholders-and-stakeholder-engagement.pdf
    June 01, 2011 - Module II: Stakeholders and Stakeholder Engagement …
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/King.pdf
    January 01, 2002 - Systemwide Deployment of Medical Team Training: Lessons Learned in the Department of Defense 425 Systemwide Deployment of Medical Team Training: Lessons Learned in the Department of Defense Heidi B. King, Beth Kohsin, Mary Salisbury Abstract Advancing to a culture of safety requires a systems change. Teamw…
  16. digital.ahrq.gov/sites/default/files/docs/publication/uc1hs016151-mathews-final-report-2008.pdf
    January 01, 2008 - Browsersoft supports a number of different processing for these updates based on the capabilities of
  17. digital.ahrq.gov/2020-year-review/research-summary/improving-care-transitions-hospitalized-patients-pharmacy-integrated-transitions-program
    January 01, 2020 - Improving Care Transitions of Hospitalized Patients With the Pharmacy Integrated Transitions Program Standardizing the hospital-to-skilled nursing facility transition by using a structured handoff between clinical teams along with a pharmacist to monitor patient medications during the transition may improve care co…
  18. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit6-2.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 6.2. Horizon Hospital—Lakeview Healthcare Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare Case 2. C…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40928/psn-pdf
    May 04, 2012 - Decision-making processes used by nurses during intravenous drug preparation and administration. May 4, 2012 Dougherty L, Sque M, Crouch R. Decision-making processes used by nurses during intravenous drug preparation and administration. J Adv Nurs. 2012;68(6):1302-11. doi:10.1111/j.1365-2648.2011.05838.x. https://…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42405/psn-pdf
    July 10, 2013 - The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach. July 10, 2013 Lucchiari C, Pravettoni G. The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach. Eur J Intern Med. 2013;24(5):411-5. doi:10.1016/j.ejim.2013.01.022. ht…