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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.
…
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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…
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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…
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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…
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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:/…
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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…
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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…
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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…
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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…
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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…
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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. …
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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…
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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 …
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effectivehealthcare.ahrq.gov/sites/default/files/module-ii-stakeholders-and-stakeholder-engagement.pdf
June 01, 2011 - Module II: Stakeholders and Stakeholder Engagement
…
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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…
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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
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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…
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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…
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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://…
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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…