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psnet.ahrq.gov/issue/incorporation-patient-safety-board-certification-examinations
October 26, 2010 - Commentary
The incorporation of patient safety into board certification examinations.
Citation Text:
Kachalia A, Johnson J, Miller ST, et al. The incorporation of patient safety into board certification examinations. Acad Med. 2006;81(4):317-25.
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psnet.ahrq.gov/issue/persistence-unsafe-practice-everyday-work-exploration-organizational-and-psychological
April 06, 2011 - Study
Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room.
Citation Text:
Espin S, Lingard L, Baker GR, et al. Persistence of unsafe practice in everyday work: an exploration of organizati…
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psnet.ahrq.gov/issue/evaluation-preoperative-team-briefing-new-communication-routine-results-improved-clinical
April 06, 2011 - Study
Evaluation of a preoperative team briefing: a new communication routine results in improved clinical practice.
Citation Text:
Lingard LA, Regehr G, Cartmill C, et al. Evaluation of a preoperative team briefing: a new communication routine results in improved clinical practice. BM…
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psnet.ahrq.gov/issue/patient-and-family-empowerment-agents-ambulatory-care-safety-and-quality
December 15, 2021 - Commentary
Patient and family empowerment as agents of ambulatory care safety and quality.
Citation Text:
Roter DL, Wolff JL, Wu AW, et al. Patient and family empowerment as agents of ambulatory care safety and quality. BMJ Qual Saf. 2017;26(6):508-512. doi:10.1136/bmjqs-2016-005489.
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psnet.ahrq.gov/issue/root-cause-analysis-transfusion-error-identifying-causes-implement-changes
August 15, 2018 - Commentary
Root cause analysis of transfusion error: identifying causes to implement changes.
Citation Text:
Elhence P, Veena S, Sharma RK, et al. Root cause analysis of transfusion error: identifying causes to implement changes. Transfusion (Paris). 2010;50(12 Pt 2):2772-2777. doi:10.…
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psnet.ahrq.gov/issue/sleep-deprivation-and-starvation-hospitalised-patients-how-medical-care-can-harm-patients
September 27, 2017 - Commentary
Sleep deprivation and starvation in hospitalised patients: how medical care can harm patients.
Citation Text:
Xu T, Wick EC, Makary MA. Sleep deprivation and starvation in hospitalised patients: how medical care can harm patients. BMJ Qual Saf. 2016;25(5):311-314. doi:10.1136/…
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psnet.ahrq.gov/issue/clinical-scenarios-enhancing-skill-set-nurse-vigilant-guardian
July 19, 2023 - Study
Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian.
Citation Text:
Jacobson T, Belcher E, Sarr B, et al. Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian. J Contin Educ Nurs. 2010;41(8):347-53; quiz 354-5. doi:10.3928/0…
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www.ahrq.gov/cpi/centers/oms/index.html
January 01, 2021 - Office of Management Services (OMS)
Directs and coordinates the Agency's administrative services and operational activities, including contracts, financial management, grants, and human capital management.
The Executive Officer and Director of OMS is Jay Toven .
Specifically, OMS provides leadership, overs…
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psnet.ahrq.gov/issue/learning-failure-need-independent-safety-investigation-healthcare
September 24, 2018 - Commentary
Learning from failure: the need for independent safety investigation in healthcare.
Citation Text:
Macrae C, Vincent CA. Learning from failure: the need for independent safety investigation in healthcare. J R Soc Med. 2014;107(11):439-443. doi:10.1177/0141076814555939.
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psnet.ahrq.gov/issue/using-medical-emergency-team-manage-anaphylactic-shock
June 26, 2024 - Commentary
Using a medical emergency team to manage anaphylactic shock.
Citation Text:
Burns B, Beckett J, Jones D, et al. Using a medical emergency team to manage anaphylactic shock. Jt Comm J Qual Patient Saf. 2008;34(6):360-3.
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www.ahrq.gov/news/newsroom/press-releases/guiding-principles.html
December 01, 2023 - Guiding Principles Help Healthcare Community Address Potential Bias Resulting from Algorithms
Press Release Date: December 15, 2023
A new paper addresses the use of algorithms in healthcare, their impact on racial/ethnic disparities in care, and approaches to identify and mitigate biases.
A paper published toda…
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www.ahrq.gov/news/newsroom/press-releases/antibiotic-prescribing.html
July 01, 2022 - New Study Shows Reductions in Antibiotic Use at Ambulatory Care Clinics Participating in HHS-funded Program
Press Release Date: July 6, 2022
Antibiotic prescribing at ambulatory care clinics was cut almost in half in clinics that participated in a safety program funded by the Department of Health and Human Servic…
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psnet.ahrq.gov/issue/harm-hope-and-purposeful-action-what-could-we-do-after-francis
August 01, 2016 - Commentary
From harm to hope and purposeful action: what could we do after Francis?
Citation Text:
Woodhead T, Lachman P, Mountford J, et al. From harm to hope and purposeful action: what could we do after Francis? BMJ Qual Saf. 2014;23(8):619-23. doi:10.1136/bmjqs-2013-002581.
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www.ahrq.gov/news/newsroom/case-studies/202501.html
January 01, 2025 - Henry Ford Hospital Unit Lowers C. diff Infections by 90 Percent Using AHRQ Safety Program
Search All Impact Case Studies
January 2025
Using AHRQ’s Comprehensive Unit-based Safety Program (CUSP ), Henry Ford Hospital in Detroit reduced the incidence of Clostridioides difficile (C. diff) infections in its…
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psnet.ahrq.gov/issue/how-does-patient-safety-culture-operating-room-and-post-anesthesia-care-unit-compare-rest
October 14, 2009 - Study
How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital?
Citation Text:
Kaafarani HMA, Itani KMF, Rosen AK, et al. How does patient safety culture in the operating room and post-anesthesia care unit compare to the re…
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psnet.ahrq.gov/issue/care-management-implementation-and-patient-safety
July 14, 2010 - Study
Care management implementation and patient safety.
Citation Text:
Care management implementation and patient safety. Alexander JA; Weiner BJ; Baker LC; et al. J Patient Saf. 2006;2(2):83-96.
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psnet.ahrq.gov/issue/virginia-tech-sentinel-event-role-psychiatry-managing-emotionally-troubled-students-college
April 24, 2018 - Commentary
Virginia Tech as a sentinel event: the role of psychiatry in managing emotionally troubled students on college and university campuses.
Citation Text:
Giggie MA. Virginia Tech as a Sentinel Event: The Role of Psychiatry in Managing Emotionally Troubled Students on College and …
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psnet.ahrq.gov/issue/effect-crew-resource-management-diabetes-care-and-patient-outcomes-inner-city-primary-care
November 24, 2010 - Study
Effect of crew resource management on diabetes care and patient outcomes in an inner-city primary care clinic.
Citation Text:
Taylor CR, Hepworth JT, Buerhaus P, et al. Effect of crew resource management on diabetes care and patient outcomes in an inner-city primary care clinic. …
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psnet.ahrq.gov/issue/expanded-pharmacy-technician-roles-accepting-verbal-prescriptions-and-communicating
October 05, 2011 - Commentary
Expanded pharmacy technician roles: accepting verbal prescriptions and communicating prescription transfers.
Citation Text:
Frost TP, Adams AJ. Expanded pharmacy technician roles: Accepting verbal prescriptions and communicating prescription transfers. Res Social Adm Pharm. 20…
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psnet.ahrq.gov/issue/impact-preoperative-briefings-operating-room-delays
July 28, 2010 - Study
Impact of preoperative briefings on operating room delays.
Citation Text:
Nundy S, Mukherjee A, Sexton B, et al. Impact of preoperative briefings on operating room delays: a preliminary report. Arch Surg. 2008;143(11):1068-72. doi:10.1001/archsurg.143.11.1068.
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