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2321. A resident-led institutional patient safety and quality improvement process. | PSNet
      psnet.ahrq.gov/issue/resident-led-institutional-patient-safety-and-quality-improvement-process
      November 16, 2022 - Study A resident-led institutional patient safety and quality improvement process. Citation Text: Stueven J, Sklar DP, Kaloostian P, et al. A resident-led institutional patient safety and quality improvement process. Am J Med Qual. 2012;27(5):369-76. doi:10.1177/1062860611429387. Cop…

2322. Implementation of an ED Passive Tracking System Using a Business Process Approach (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/2006LaskowskiJones_051711comp2.pdf
      June 01, 2005 - Implementation of an ED Passive Tracking System Using a Business Process Approach Implementation of an ED Passive Tracking System Using a Business Process Approach Business Process Development Implementation Effects Analysis Linda Laskowski Jones RN, MS, APRN, BC, CCRN, CEN Vice President: Emergency, Trauma & A…

2323. Closing the loop: a process evaluation of inpatient care team communication. | PSNet
      psnet.ahrq.gov/issue/closing-loop-process-evaluation-inpatient-care-team-communication
      March 09, 2019 - Study Closing the loop: a process evaluation of inpatient care team communication. Citation Text: Broman KK, Kensinger C, Hart H, et al. Closing the loop: a process evaluation of inpatient care team communication. BMJ Qual Saf. 2017;26(1):30-32. doi:10.1136/bmjqs-2015-004580. Copy Cita…

2324. Rooting an error review process in just culture: lessons learned. | PSNet
      psnet.ahrq.gov/issue/rooting-error-review-process-just-culture-lessons-learned
      April 20, 2022 - Commentary Rooting an error review process in just culture: lessons learned. Citation Text: Neiswender K, Figueroa-Altmann A, Granahan K, et al. Rooting an error review process in just culture: lessons learned. Patient Safety. 2022;4(3):34-38. doi:10.33940/culture/2022.9.5. Copy Citati…

2325. Improving process while changing practice: FMEA and medication administration. | PSNet
      psnet.ahrq.gov/issue/improving-process-while-changing-practice-fmea-and-medication-administration
      January 18, 2011 - Commentary Improving process while changing practice: FMEA and medication administration. Citation Text: Riehle MA, Bergeron D, Hyrkäs K. Improving process while changing practice. Nurs Manage. 2009;39(2). doi:10.1097/01.numa.0000310533.54708.38. Copy Citation Format: DOI…

2326. Actions Needed to Address Employee Misconduct Process and Ensure Accountability. | PSNet
      psnet.ahrq.gov/issue/actions-needed-address-employee-misconduct-process-and-ensure-accountability
      July 11, 2018 - Book/Report Actions Needed to Address Employee Misconduct Process and Ensure Accountability. Citation Text: Actions Needed to Address Employee Misconduct Process and Ensure Accountability. Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137. …

2327. Improving the Emergency Department Discharge Process | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/emergency-dept/discharge-process.html
      July 01, 2017 - Improving the Emergency Department Discharge Process Millions of patients visit hospital emergency departments (EDs) each year for a variety of injuries and ailments. A sizable minority of ED patients returns to the ED frequently and account for a disproportionately large share of overall visits and…

2328. Final Report: Embracing the PBRN Model To Improve the Medication Use Process (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/lipowski-report.pdf
      January 01, 2024 - Final Report: Embracing the PBRN Model To Improve the Medication Use Process Embracing the PBRN Model to Improve the Medication Use Process Final Report for Conference Grant 1 R13 HS016844 01 Principal Investigator: Earlene E. Lipowski, PhD Grantee Institution: University of Florida Division of Sponsored Resear…

2329. The cost of poor blood specimen quality and errors in preanalytical processes. | PSNet
      psnet.ahrq.gov/issue/cost-poor-blood-specimen-quality-and-errors-preanalytical-processes
      April 22, 2009 - Review The cost of poor blood specimen quality and errors in preanalytical processes. Citation Text: Green SF. The cost of poor blood specimen quality and errors in preanalytical processes. Clin Biochem. 2013;46(13-14):1175-9. doi:10.1016/j.clinbiochem.2013.06.001. Copy Citation F…

2330. Healthcare failure mode and effect analysis in the chemotherapy preparation process. | PSNet
      psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-chemotherapy-preparation-process
      March 09, 2022 - Study Healthcare failure mode and effect analysis in the chemotherapy preparation process. Citation Text: Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. Healthcare failure mode and effect analysis in the chemotherapy preparation process. J Oncol Pharm Pract. 2021;27(7):15…

2331. Using Six Sigma to improve patient safety in the perioperative process. | PSNet
      psnet.ahrq.gov/issue/using-six-sigma-improve-patient-safety-perioperative-process
      June 27, 2018 - Newspaper/Magazine Article Using Six Sigma to improve patient safety in the perioperative process. Citation Text: Using Six Sigma to improve patient safety in the perioperative process. Galli BJ, Riebling N, Paraso C, Lehmann G, Yule M. Patient Saf Qual Healthc. July/August 2013;10:36-41…

2332. 2014 Annual Benchmarking Report: Malpractice Risks in the Diagnostic Process. | PSNet
      psnet.ahrq.gov/issue/2014-annual-benchmarking-report-malpractice-risks-diagnostic-process
      September 26, 2012 - Book/Report 2014 Annual Benchmarking Report: Malpractice Risks in the Diagnostic Process. Citation Text: 2014 Annual Benchmarking Report: Malpractice Risks in the Diagnostic Process. Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014. Copy Citation Save Save to …

2333. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840256/psn-pdf
      November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD November 16, 2022 In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd Editor’s note: Dr. Pascale Carayon, PhD, is a p…

2334. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49681/psn-pdf
      April 01, 2013 - Total Parenteral Nutrition, Multifarious Errors April 1, 2013 Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors Case Objectives Define parenteral nutrition (PN). Describe the PN-use process. Identify …

2335. Learn From Defects in Care of Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html
      February 01, 2017 - Learn From Defects in Care of Mechanically Ventilated Patients: Facilitator Guide AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: Learn From Defects in Care of Mechanically Ventilated Patients Say: In this module, we will discuss the Learning From Defects tool. It is a very useful proc…

2336. Assessing the Risk of Bias in Systematic Reviews of Health Care Interventions (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/ehc-presentation-risk-of-bias.pdf
      December 01, 2017 - Assessing the Risk of Bias in Systematic Reviews of Health Care Interventions Assessing the Risk of Bias in Systematic Reviews of Health Care Interventions Prepared for: The Agency for Healthcare Research and Quality (AHRQ) Training Modules for Systematic Reviews Methods Guide www.ahrq.gov Presenter Presentation …

2337. Supporting Continuity of Care for Poisonings with Electronic Information Exchange (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r21hs018773-cummins-final-report-2013.pdf
      January 01, 2013 - Supporting Continuity of Care for Poisonings with Electronic Information Exchange 1  Supporting Continuity of Care for Poisonings with Electronic Information Exchange Principal Investigator: Mollie R. Cummins, PhD, RN (nee Poynton) Co-Investigators: Barbara I. Crouch, PharmD, MSPH, Per Gesteland, MD, MSc …

2338. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet
      psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
      February 26, 2025 - In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025  Also Read the Essay View more articles from the same authors. Citation T…

2339. The Evolution of Root Cause Analysis | PSNet
      psnet.ahrq.gov/perspective/evolution-root-cause-analysis
      February 26, 2025 - The Evolution of Root Cause Analysis Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Behrhorst J, Gale B, Van CM. Th…

2340. Final Progress Report: Measuring Quality of Primary Care in Complex Pediatric Patients (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/chen-report.pdf
      January 01, 2025 - Final Progress Report: Measuring Quality of Primary Care in Complex Pediatric Patients Title: Measuring Quality of Primary Care in Complex Pediatric Patients Principal Investigator: Alex Y. Chen, MD, MS Organization: Children’s Hospital Los Angeles Inclusive Dates of Project: 07/01/2009- 06/30/2012 Federal Projec…