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9801. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867340/psn-pdf
      December 11, 2024 - Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: a mixed methods analysis. December 11, 2024 Brown AJ, Yardley S, Bowers B, et al. Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: a mixed…

9802. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40596/psn-pdf
      December 31, 2014 - Errors associated with outpatient computerized prescribing systems. December 31, 2014 Nanji KC, Rothschild JM, Salzberg C, et al. Errors associated with outpatient computerized prescribing systems. J Am Med Inform Assoc. 2011;18(6):767-73. doi:10.1136/amiajnl-2011-000205. https://psnet.ahrq.gov/issue/errors-associ…

9803. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851200/psn-pdf
      July 05, 2023 - Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia. July 5, 2023 Washington DC:  Department of Veterans Affairs, Office of Inspector General; May 10, 2023.  Report no. 22-01116-110. https://psnet.ahrq.gov/issue/defi…

9804. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60277/psn-pdf
      January 01, 2021 - Evidence that nurses need to participate in diagnosis: lessons from malpractice claims. April 29, 2020 Gleason KT, Jones RM, Rhodes C, et al. Evidence that nurses need to participate in diagnosis: lessons from malpractice claims. J Patient Saf. 2021;17(8):e959-e963. doi:10.1097/pts.0000000000000621. https://psnet.…

9805. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45922/psn-pdf
      April 19, 2017 - Two sides to every story: the Dual Perspectives Method for examining interruptions in healthcare. April 19, 2017 McCurdie T, Sanderson P, Aitken LM, et al. Two sides to every story: The Dual Perspectives Method for examining interruptions in healthcare. Appl Ergon. 2017;58:102-109. doi:10.1016/j.apergo.2016.05.012.…

9806. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46124/psn-pdf
      April 17, 2018 - Improving the safety of health information technology requires shared responsibility: it is time we all step up. April 17, 2018 Sittig DF, Belmont E, Singh H. Improving the safety of health information technology requires shared responsibility: It is time we all step up. Healthc (Amst). 2017;6(1):7-12. doi:10.1016/…

9807. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41703/psn-pdf
      November 08, 2012 - Anatomy of an incident disclosure: the importance of dialogue. November 8, 2012 Iedema R, Allen S. Anatomy of an incident disclosure: the importance of dialogue. Jt Comm J Qual Patient Saf. 2012;38(10):435-42. https://psnet.ahrq.gov/issue/anatomy-incident-disclosure-importance-dialogue Physician organizations who…

9808. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47403/psn-pdf
      November 07, 2018 - Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition. November 7, 2018 Triller D, Myrka A, Gassler J, et al. Defining Minimum Necessary Anticoagulation-Related Communication at Discharge: Consens…

9809. Background | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/measure_retirement/measure_retirement2.html
      February 01, 2014 - Background Report on 2013 Retirement of Measures from the Child Core Set Background Previous Page Next Page Table of Contents Background Report on 2013 Retirement of Measures from the Child Core Set Abstract Background Methods Results Conclusions References Appendix A. Appendix B. …

9810. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43363/psn-pdf
      September 12, 2016 - Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. September 12, 2016 Johnston MJ, Arora S, King D, et al. Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. Surgery. 2014;155(6):989-94. doi:10.1016/j.surg.2014.01.016. https://ps…

9811. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46031/psn-pdf
      April 12, 2017 - Chief of Residents for Quality Improvement and Patient Safety: a recipe for a new role in graduate medical education. April 12, 2017 Ferraro K, Zernzach R, Maturo S, et al. Chief of Residents for Quality Improvement and Patient Safety: A Recipe for a New Role in Graduate Medical Education. Mil Med. 2017;182(3):e17…

9812. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867229/psn-pdf
      January 01, 2025 - Feasibility of prospective error reporting in home palliative care: a mixed methods study. December 4, 2024 Kurahashi AM, Kim G, Parry N, et al. Feasibility of prospective error reporting in home palliative care: a mixed methods study. Palliat Med. 2025;39(1):22-30. doi:10.1177/02692163241288774. https://psnet.ahr…

9813. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60524/psn-pdf
      May 27, 2020 - Varying rates of patient identity verification when using computerized provider order entry. May 27, 2020 Fortman E, Hettinger AZ, Howe JL, et al. Varying rates of patient identity verification when using computerized provider order entry. J Am Med Info Assoc. 2020;27(6):924-928. doi:10.1093/jamia/ocaa047. https:/…

9814. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45500/psn-pdf
      September 28, 2016 - PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique. September 28, 2016 Barry E, O'Brien K, Moriarty F, et al. PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary…

9815. Using the AHRQ Pharmacy Survey on Patient Safety Culture (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/amermanslides.pdf
      June 02, 2025 - Using the AHRQ Pharmacy Survey on Patient Safety Culture Safety Survey Dawn Amerman Manager Dexter Pharmacy and Village Pharmacy II Reasons for Taking the Survey • Provided staff with an opportunity to give uncensored feedback • Offered staff a sense of being part of the solutions • Let staff know t…

9816. IMPLEMENT California Quality Improvement Collaborative Agenda (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/sample-agenda.pdf
      June 02, 2025 - IMPLEMENT California Quality Improvement Collaborative Agenda IMPLEMENT California Quality Improvement Collaborative Agenda TIME TOPIC 7:30-8:00 Registration and Continental Breakfast 8:00-8:30 Welcome and Introductions 8:30-8:45 AHRQ PQMP: IMPLEMENT Project Overview 8:45-9:00 Family Perspective –…

9817. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44577/psn-pdf
      October 21, 2015 - Improving patient safety in clinical oncology: applying lessons from Normal Accident Theory. October 21, 2015 Chera BS, Mazur L, Buchanan I, et al. Improving Patient Safety in Clinical Oncology: Applying Lessons From Normal Accident Theory. JAMA Oncol. 2015;1(7):958-64. doi:10.1001/jamaoncol.2015.0891. https://psn…

9818. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36303/psn-pdf
      October 25, 2010 - Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. October 25, 2010 Poon EG, Cina J, Churchill WW, et al. Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. …

9819. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36407/psn-pdf
      April 19, 2011 - Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit. April 19, 2011 Gillman L, Leslie G, Williams T, et al. Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit…

9820. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843329/psn-pdf
      February 01, 2023 - Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology. February 1, 2023 Chew MM, Rivas S, Chesser M, et al. Improving administration and documentation of enteral nutrition su…