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www.ahrq.gov/talkingquality/translate/scores/index.htmlMarch 01, 2016 - Generating Health Care Quality Scores That Show Differences The critical link between collecting performance information and sharing that information with others is the process of generating scores. The nature of the score is often inherent in the measure (e.g., an overall rating on a 1-10 scale). But even in…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45510/psn-pdfOctober 19, 2016 - How to perform a root cause analysis for workup and future prevention of medical errors: a review. October 19, 2016 Charles R, Hood B, DeRosier JM, et al. How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient Saf Surg. 2016;10:20. doi:10.1186/s13037-016-0107-8. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47690/psn-pdfMarch 13, 2019 - I-PASS mentored implementation handoff curriculum: champion training materials. March 13, 2019 O'Toole JK, Starmer AJ, Calaman S, et al. I-PASS Mentored Implementation Handoff Curriculum: Champion Training Materials. MedEdPORTAL. 2019;15:10794. doi:10.15766/mep_2374-8265.10794. https://psnet.ahrq.gov/issue/i-pass-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46646/psn-pdfJanuary 01, 2021 - Impact of an original methodological tool on the identification of corrective and preventive actions after root cause analysis of adverse events in health care facilities: results of a randomized controlled trial. December 20, 2017 Vacher A, El Mhamdi S, d?Hollander A, et al. Impact of an Original Methodological T… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/844047/psn-pdfFebruary 08, 2023 - Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure. February 8, 2023 Klasen JM, Beck J, Randall CL, et al. Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure. Acad Pediatr. 2023;23(2):489-496. doi:… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72798/psn-pdfMarch 03, 2021 - Perceptual gaps between clinicians and technologists on health information technology-related errors in hospitals: observational study. March 3, 2021 Ndabu T, Mulgund P, Sharman R, et al. Perceptual gaps between clinicians and technologists on health information technology-related errors in hospitals: observationa… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/43799/psn-pdfJanuary 07, 2015 - Omission of high-alert medications: a hidden danger. January 7, 2015 Grissinger M, Alghamdi D. PA-PSRS Patient Saf Advis. December 2014;11:149-155. https://psnet.ahrq.gov/issue/omission-high-alert-medications-hidden-danger Analyzing incidents reported over a 4-month period, this article reveals that 21% of 2700 med… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46357/psn-pdfMay 17, 2018 - Safe labeling practices to minimize medication errors in anesthesia: 5 case reports and review of the literature. May 17, 2018 Prakash S, Mullick P, Kumar A, et al. Safe Labeling Practices to Minimize Medication Errors in Anesthesia. A & A Practice. 2017;10(10). doi:10.1213/xaa.0000000000000680. https://psnet.ahrq… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38054/psn-pdfJuly 05, 2013 - Ticket to ride: reducing handoff risk during hospital patient transport. July 5, 2013 Pesanka DA, Greenhouse PK, Rack LL, et al. Ticket to ride: reducing handoff risk during hospital patient transport. J Nurs Care Qual. 2009;24(2):109-15. doi:10.1097/01.NCQ.0000347446.98299.b5. https://psnet.ahrq.gov/issue/ticket-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45589/psn-pdfJanuary 23, 2017 - Do pharmacist-led medication reviews in hospitals help reduce hospital readmissions? A systematic review and meta-analysis. January 23, 2017 Renaudin P, Boyer L, Esteve M-A, et al. Do pharmacist-led medication reviews in hospitals help reduce hospital readmissions? A systematic review and meta-analysis. Br J Anaes… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/850932/psn-pdfJune 21, 2023 - Evaluation of detected medication errors within the operating room at an academic medical center. June 21, 2023 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:10.1177/00185787221145110. https://p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/867234/psn-pdfDecember 04, 2024 - Survey results reveal tubing misconnections are common and underreported—Parts I and II. December 4, 2024 Survey results reveal tubing misconnections are common and underreported—Parts I and II. ISMP Medication Safety Alert! Acute Care. October 31, 2024;29(22 & 23):1-5;1-4. https://psnet.ahrq.gov/issue/survey-resu… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/47180/psn-pdfNovember 15, 2018 - Efficacy and unintended consequences of hard-stop alerts in electronic health record systems: a systematic review. November 15, 2018 Powers EM, Shiffman RN, Melnick ER, et al. Efficacy and unintended consequences of hard-stop alerts in electronic health record systems: a systematic review. J Am Med Inform Assoc. 2… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/46346/psn-pdfOctober 29, 2017 - Root cause analysis of ICU adverse events in the Veterans Health Administration. October 29, 2017 Corwin GS, Mills PD, Shanawani H, et al. Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2017;43(11):580-590. doi:10.1016/j.jcjq.2017.04.009. https://psnet.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/37984/psn-pdfAugust 13, 2008 - Planning and implementing a systems-based patient safety curriculum in medical education. August 13, 2008 Thompson DA, Cowan J, Holzmueller CG, et al. Planning and implementing a systems-based patient safety curriculum in medical education. Am J Med Qual. 2008;23(4):271-8. doi:10.1177/1062860608317763. https://ps… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/45296/psn-pdfSeptember 21, 2016 - Comparison of medication safety systems in critical access hospitals: combined analysis of two studies. September 21, 2016 Cochran GL, Barrett RS, Horn SD. Comparison of medication safety systems in critical access hospitals: Combined analysis of two studies. Am J Health Syst Pharm. 2016;73(15):1167-73. doi:10.214… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/858170/psn-pdfDecember 13, 2023 - Unsafe care in residential settings for older adults. A content analysis of accreditation reports. December 13, 2023 Hibbert PD, Ash R, Molloy CJ, et al. Unsafe care in residential settings for older adults: a content analysis of accreditation reports. Int J Qual Health Care. 2023;35(4):mzad085. doi:10.1093/intqhc/… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837705/psn-pdfJuly 20, 2022 - Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals. July 20, 2022 Xiao Y, Smith A, Abebe E, et al. Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/44038/psn-pdfMay 06, 2015 - Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. May 6, 2015 Marks L, Mazur L, Chera B, Adams R. Boca Raton, FL: Productivity Press; 2015. ISBN: 9781482233643. https://psnet.ahrq.gov/issue/engineering-patient-safety-radiation-oncology… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/840479/psn-pdfJanuary 01, 2023 - A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items. November 30, 2022 Carmack A, Valleru J, Randall KH, et al. A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items. Jt Comm J Qual Patient Saf. 2023;49(1):3-13. doi:10.…
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