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psnet.ahrq.gov/issue/application-human-factors-methods-understand-missed-follow-abnormal-test-results
December 16, 2020 - Study
Application of human factors methods to understand missed follow-up of abnormal test results.
Citation Text:
Rogith D, Satterly T, Singh H, et al. Application of human factors methods to understand missed follow-up of abnormal test results. Appl Clin Inform. 2020;11(05):692-698. do…
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psnet.ahrq.gov/issue/case-safety-leadership-team-training-hospital-managers
August 31, 2011 - Study
A case for safety leadership team training of hospital managers.
Citation Text:
Singer SJ, Hayes J, Cooper JB, et al. A case for safety leadership team training of hospital managers. Health Care Manage Rev. 2011;36(2):188-200. doi:10.1097/HMR.0b013e318208cd1d.
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psnet.ahrq.gov/issue/five-year-audit-adherence-anaesthesia-pre-induction-checklist
May 19, 2021 - Study
Five-year audit of adherence to an anaesthesia pre-induction checklist.
Citation Text:
Fuchs A, Frick S, Huber M, et al. Five‐year audit of adherence to an anaesthesia pre‐induction checklist. Anaesthesia. 2022;77(7):751-762. doi:10.1111/anae.15704.
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psnet.ahrq.gov/issue/attending-physician-remote-access-electronic-health-record-and-implications-resident
September 22, 2010 - Study
Attending physician remote access of the electronic health record and implications for resident supervision: a mixed methods study.
Citation Text:
Martin SK, Tulla K, Meltzer DO, et al. Attending Physician Remote Access of the Electronic Health Record and Implications for Resident …
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digital.ahrq.gov/ahrq-funded-projects/health-information-technology-ambulatory-care-settings-effects-quality-and-disparities
January 01, 2023 - Health Information Technology in Ambulatory Care Settings: Effects on Quality and Disparities
Project Final Report ( PDF , 106.85 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not …
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psnet.ahrq.gov/issue/minor-flow-disruptions-traffic-related-factors-and-their-effect-major-flow-disruptions
August 19, 2020 - Study
Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room.
Citation Text:
Joseph A, Khoshkenar A, Taaffe KM, et al. Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating roo…
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psnet.ahrq.gov/issue/characterising-icu-ward-handoffs-three-academic-medical-centres-process-and-perceptions
September 27, 2023 - Study
Characterising ICU–ward handoffs at three academic medical centres: process and perceptions.
Citation Text:
Santhosh L, Lyons PG, Rojas JC, et al. Characterising ICU-ward handoffs at three academic medical centres: process and perceptions. BMJ Qual Saf. 2019;28(8):627-634. doi:10.1…
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psnet.ahrq.gov/issue/collapse-sensemaking-organizations-mann-gulch-disaster
May 21, 2019 - Commentary
Classic
The collapse of sensemaking in organizations: the Mann Gulch disaster.
Citation Text:
Weick KE. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. Admin Sci Q. 2006;38(4):628-652. doi:10.2307/2393339.
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psnet.ahrq.gov/issue/perfect-storm-exam-medical-error-and-factors-contributing-its-possible-escalation
October 20, 2021 - Commentary
The perfect storm: exam of a medical error and factors contributing to its possible escalation.
Citation Text:
Walters GK. The perfect storm: exam of a medical error and factors contributing to its possible escalation. J Patient Saf. 2021;17(4):e264-e267. doi:10.1097/pts.00000…
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psnet.ahrq.gov/issue/language-proficiency-and-adverse-events-us-hospitals-pilot-study
January 23, 2012 - Study
Language proficiency and adverse events in US hospitals: a pilot study.
Citation Text:
Divi C, Koss RG, Schmaltz SP, et al. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19(2):60-67. doi:10.1093/intqhc/mzl069.
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www.ahrq.gov/sites/default/files/publications/files/pharmlit.pdf
October 01, 2007 - the
Pharmacy Assessment Tour Guide
(Appendix 2), which consists of the
following three sections:
• Promotion … responses within any one
section identified any single area as
stronger or weaker than other areas
(i.e., promotion … Promotion of Services
This section asks questions about how well the pharmacy tells patients about its
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/carbapenem-resistant-1.pdf
March 01, 2020 - Comments
Rossi
Gonçalves
et al., 201616
Multicomponent
intervention that
included hand
hygiene
promotion … control
measures were
strengthened at the
time of the first
outbreak to include
hand hygiene
promotion … managed with strict CP; (c)
intensification of education,
cleaning, and handwashing
programs; and (d) promotion
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effectivehealthcare.ahrq.gov/products/worker-health/research
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/patient-safety-practices_research-protocol.pdf
November 09, 2011 - Evidence-based Practice Center Systematic Review Protocol
Source: www.effectivehealthcare.ahrq.gov
Published Online: November 9, 2011
Evidence-based Practice Center Systematic Review Protocol
Project Title: Critical Analysis of the Evidence for Patient Safety Practices
I. Background and Objectives fo…
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psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - Opioid Overdose as a Patient Safety Problem
May 22, 2017
Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
Perspective
Opioids serve a valuable role in the treatment of acute pain and pain associat…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_PFE_Benefits_Hosp_508.docx
January 01, 2012 - Information to Help Hospitals Get Started
How Patient and Family Engagement
Benefits Your Hospital
Information to Help Hospitals Get Started
[Type text] [Type text] [Type text]
Information to Help Hospitals Get Started
Guide to Patient and Family Engagement :: 1
Guide to Patient and Family Engagement :: 1
Patien…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-unc-webcast-fenton-wilhelm-amos.pdf
August 15, 2019 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Fenton-Wilhelm-Amos
U
N
C H E A L T H C A R E S Y S T E M
U
N
C H E A L T H C A R E
Culture of Safety Improvement Project
UNC Medical Center
29
U
N
C H …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/tiered-approach-notes.docx
April 01, 2022 - Using a Tiered Approach With CUSP Principles Facilitator Guide
CUSP Module: Using a Tiered Approach With CUSP Principles
Facilitator Guide
Slide Number and Image
This module, titled “Using a Tiered Approach with CUSP Principles” is part of the Agency for Healthcare Research and Quality, or AHRQ, Safety Program …
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psnet.ahrq.gov/node/33564/psn-pdf
March 15, 2025 - Computerized Provider Order Entry
March 15, 2025
Computerized Provider Order Entry. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/computerized-provider-order-entry
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice…
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psnet.ahrq.gov/innovation/critical-radiology-alert-process
November 16, 2022 - Critical Radiology Alert Process
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