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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73662/psn-pdf
    September 01, 2021 - Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review. September 1, 2021 Petrosoniak A, Fan M, Hicks CM, et al. Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation u…

  2. Exhibit 12. Probability of an intervention reducing the risk of surgical site infection (SSI) by interventions targeting component failure points individually | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/final-reports/stpra/stpraexh12.html
    April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Exhibit 12. Probability of an intervention reducing the risk of surgical site infection (SSI) by interventions targeting component failure points individually Previous Page Next Page Table of Contents Proactive Risk A…

  3. Comparing Quality Scores to an Independent Standard | Agency for Healthcare Research and Quality

    www.ahrq.gov/talkingquality/translate/compare/choose/standard.html
    January 01, 2023 - Comparing Quality Scores to an Independent Standard Another approach would be to compare scores to an independent standard of what performance on this measure ideally should be . While implementing this approach is challenging, it has significant advantages. Advantages of Comparing to an Independent Standard…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60048/psn-pdf
    March 18, 2020 - 'Immunising' physicians against availability bias in diagnostic reasoning: a randomised controlled experiment. March 18, 2020 Mamede S, de Carvalho-Filho MA, de Faria RMD, et al. ‘Immunising’ physicians against availability bias in diagnostic reasoning: a randomised controlled experiment. BMJ Qual Saf. 2020;29(7):…

  5. New Ideas Lead to Big Changes in Care | Agency for Healthcare Research and Quality

    www.ahrq.gov/evidencenow/projects/heart-health/about/stories/in-action/cascades-east.html
    March 01, 2021 - New Ideas Lead to Big Changes in Care Like many small- and medium-sized practices, the team at Cascades East Family Medicine is always searching for ways to improve care. For Cascades East, this meant enrolling in EvidenceNOW, which connected them with a practice facilitator, Mr. Steven Brantley. In their wor…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862992/psn-pdf
    February 21, 2024 - Evaluating independent double checks in the pediatric intensive care unit: a human factors engineering approach. February 21, 2024 Konwinski L, Steenland C, Miller K, et al. Evaluating independent double checks in the pediatric intensive care unit: a human factors engineering approach. J Patient Saf. 2024;20(3):20…

  7. Exhibit 4.11. Dissemination of Results from Lean Projects Throughout the Organization | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-11.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 4.11. Dissemination of Results from Lean Projects Throughout the Organization Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Cas…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37891/psn-pdf
    June 09, 2011 - Classifying and predicting errors of inpatient medication reconciliation. June 9, 2011 Pippins JR, Gandhi TK, Hamann C, et al. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med. 2008;23(9):1414-22. doi:10.1007/s11606-008-0687-9. https://psnet.ahrq.gov/issue/classifying-and-…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47069/psn-pdf
    June 18, 2021 - Physical and verbal violence against health care workers. June 18, 2021 Physical and verbal violence against health care workers. Sentinel Event Alert. 2018;59:1-9 (revised June 18, 2021). https://psnet.ahrq.gov/issue/physical-and-verbal-violence-against-health-care-workers The Joint Commission issues sentinel eve…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60361/psn-pdf
    May 20, 2020 - Novel, High-Impact Studies Evaluating Health System and Healthcare Professional Responsiveness to COVID-19 (R01). May 20, 2020 Rockville, MD: Agency for Healthcare Research and Quality; May 14, 2020. https://psnet.ahrq.gov/issue/novel-high-impact-studies-evaluating-health-system-and-healthcare- professional-respo…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867384/psn-pdf
    December 18, 2024 - Involving patients and/or their next of kin in serious adverse event investigations: a qualitative study on hospital perspectives. December 18, 2024 Knap LJ, Dijkstra-Eijkemans RI, Friele RD, et al. Involving patients and/or their next of kin in serious adverse event investigations: a qualitative study on hospital…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72568/psn-pdf
    January 01, 2021 - Alternatives to opioid education and a prescription drug monitoring program cumulatively decreased outpatient opioid prescriptions. December 16, 2020 Sigal A, Shah A, Onderdonk A, et al. Alternatives to opioid education and a prescription drug monitoring program cumulatively decreased outpatient opioid prescriptio…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45701/psn-pdf
    December 21, 2016 - Clinical decision support for drug related events: moving towards better prevention. December 21, 2016 Kane-Gill SL, Achanta A, Kellum JA, et al. Clinical decision support for drug related events: Moving towards better prevention. World J Crit Care Med. 2016;5(4):204-211. https://psnet.ahrq.gov/issue/clinical-deci…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36997/psn-pdf
    June 29, 2011 - Dispensing errors in community pharmacy: perceived influence of sociotechnical factors. June 29, 2011 Szeinbach S, Seoane-Vazquez E, Parekh A, et al. Dispensing errors in community pharmacy: perceived influence of sociotechnical factors. Int J Qual Health Care. 2007;19(4):203-9. https://psnet.ahrq.gov/issue/dispen…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74203/psn-pdf
    December 22, 2021 - Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project. December 22, 2021 Brown B, Bermingham S, Vermeulen M, et al. Surgical safety checklist audits may be misleading! Improving the implementation and adherence…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74692/psn-pdf
    January 26, 2022 - Changes made to orders placed by overnight admitting residents on teaching rounds the next day. January 26, 2022 Chiel L, Freiman E, Yarahuan J, et al. Changes made to orders placed by overnight admitting residents on teaching rounds the next day. Hosp Pediatr. 2021;12(1):e35-e38. doi:10.1542/hpeds.2021-005823. ht…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44779/psn-pdf
    May 20, 2016 - Fifteen years after To Err Is Human: a success story to learn from. May 20, 2016 Pronovost P, Cleeman JI, Wright D, et al. Fifteen years after To Err is Human: a success story to learn from. BMJ Qual Saf. 2016;25(6):396-9. doi:10.1136/bmjqs-2015-004720. https://psnet.ahrq.gov/issue/fifteen-years-after-err-human-su…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35906/psn-pdf
    May 27, 2011 - Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. May 27, 2011 Kim G, Chen AR, Arceci RJ, et al. Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. Arch Pediatr Adolesc Med. 2006;160(5):495-8. https:/…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851647/psn-pdf
    July 26, 2023 - Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas. July 26, 2023 Stierman EK, O'Brien BT, Stagg J, et al. Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas. Qual Manag Health Care. 2023;32(3):177-188. doi:10.109…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45967/psn-pdf
    July 05, 2017 - Root-cause analysis: swatting at mosquitoes versus draining the swamp. July 5, 2017 Trbovich PL, Shojania KG. Root-cause analysis: swatting at mosquitoes versus draining the swamp. BMJ Qual Saf. 2017;26(5):350-353. doi:10.1136/bmjqs-2016-006229. https://psnet.ahrq.gov/issue/root-cause-analysis-swatting-mosquitoes-…
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