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psnet.ahrq.gov/issue/former-pharmacist-indicted-manslaughter-after-med-error
October 17, 2018 - Newspaper/Magazine Article
Former pharmacist indicted for manslaughter after med error.
Citation Text:
Former pharmacist indicted for manslaughter after med error. Paul R. Drug Topics. September 17, 2007.
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psnet.ahrq.gov/issue/error-prone-conditions-lead-student-nurse-related-errors
October 31, 2012 - Newspaper/Magazine Article
Error-prone conditions that lead to student nurse-related errors.
Citation Text:
Error-prone conditions that lead to student nurse-related errors. ISMP Medication Safety Alert! Acute care edition. October 18, 2007.
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www.ahrq.gov/talkingquality/resources/podcasts-webinars.html
December 01, 2022 - Presentations on Health Care Quality Reporting Topics
Plug-In & Multimedia Help
Podcasts
How Social Media Can Draw Visitors to a Quality Report
Barbara Lambiaso and Lauren Piccolo from Massachusetts Health Quality Partners (MHQP) talk about how MHQP uses social media to promote awareness and use of comp…
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psnet.ahrq.gov/issue/patient-safety-nursing-practice-0
June 23, 2009 - Commentary
Patient safety in nursing practice.
Citation Text:
Farquhar M, Sharp BAC, Clancy CM. Patient safety in nursing practice. AORN J. 2007;86(3):455-7.
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psnet.ahrq.gov/issue/non-accidental-injuries-infants-attending-emergency-department
May 31, 2023 - Book/Report
Non-accidental Injuries in Infants Attending the Emergency Department.
Citation Text:
Non-accidental Injuries in Infants Attending the Emergency Department. Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.
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psnet.ahrq.gov/issue/closing-deaths-door-legal-innovations-end-epidemic-healthcare-harm
January 27, 2021 - Book/Report
Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm.
Citation Text:
Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm. Saks M, Landsman S. New York, NY: Oxford University Press; 2021. ISBN: 9780190667986.
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psnet.ahrq.gov/issue/computer-viruses-are-rampant-medical-devices-hospitals
February 21, 2024 - Newspaper/Magazine Article
Computer viruses are "rampant" on medical devices in hospitals.
Citation Text:
Computer viruses are "rampant" on medical devices in hospitals. Talbot D. MIT Technology Review. October 17, 2012.
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psnet.ahrq.gov/issue/achieving-exceptional-patient-and-family-experience-inpatient-hospital-care
August 09, 2017 - Book/Report
Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care.
Citation Text:
Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care. Balik B, Conway J, Zipperer L, Watson J. Cambridge, MA: Institute for Healthcare Improvement; 2…
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www.ahrq.gov/news/newsroom/case-studies/201807.html
November 01, 2018 - California Hospital Reduced Infections, Improved Diabetes Care with AHRQ Safety Program
Search All Impact Case Studies
November 2018
Tri-City Medical Center, a 388-bed hospital in Oceanside, California, reduced central line-associated bloodstream infections (CLABSIs) by 33 percent and improved the on-time d…
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psnet.ahrq.gov/issue/using-six-sigma-improve-patient-safety-perioperative-process
June 27, 2018 - Newspaper/Magazine Article
Using Six Sigma to improve patient safety in the perioperative process.
Citation Text:
Using Six Sigma to improve patient safety in the perioperative process. Galli BJ, Riebling N, Paraso C, Lehmann G, Yule M. Patient Saf Qual Healthc. July/August 2013;10:36-41…
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psnet.ahrq.gov/issue/infection-prevention-and-control-pediatric-ambulatory-settings
April 11, 2011 - Organizational Policy/Guidelines
Infection prevention and control in pediatric ambulatory settings.
Citation Text:
Infection prevention and control in pediatric ambulatory settings. Rathore MH, Jackson MA, AAP Committee on Infections Diseases. Pediatrics. 2017;140(5):e20172857.
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psnet.ahrq.gov/issue/drug-shortages-amid-covid-19-pandemic
July 10, 2019 - Newspaper/Magazine Article
Drug shortages amid the COVID-19 pandemic.
Citation Text:
Drug shortages amid the COVID-19 pandemic. Bookwalter CM. US Pharmacist. 2021;46(2):25-28.
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www.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
December 01, 2023 - Reviewing the Team's Performance: Debrief
Research has shown that teams that effectively debrief their own performance can improve their teamwork in real time. 1 , 2 , 3 , 4 Although it is often difficult to find time for such reviews in healthcare, TeamSTEPPS advocates for after-action reviews; TeamSTEPPS ch…
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psnet.ahrq.gov/issue/competitive-imperative-learning
September 25, 2024 - Commentary
The competitive imperative of learning.
Citation Text:
Edmondson A. The competitive imperative of learning. Harv Bus Rev. 2008;86(7-8):60-7, 160.
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psnet.ahrq.gov/issue/ahrq-safety-program-end-stage-renal-disease-facilities-toolkit
December 24, 2008 - Government Resource
AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit.
Citation Text:
AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; January 2015.
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psnet.ahrq.gov/issue/bringing-diagnosis-quality-and-safety-equations
October 10, 2018 - Commentary
Bringing diagnosis into the quality and safety equations.
Citation Text:
Graber ML, Wachter R, Cassel C. Bringing diagnosis into the quality and safety equations. JAMA. 2012;308(12):1211-2.
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psnet.ahrq.gov/issue/slow-troubling-death-autopsy
August 19, 2020 - Newspaper/Magazine Article
The slow, troubling death of the autopsy.
Citation Text:
The slow, troubling death of the autopsy. Ashworth S. Elemental. September 22, 2020.
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psnet.ahrq.gov/issue/criminalization-mistakes-nursing
June 13, 2011 - Commentary
The criminalization of mistakes in nursing.
Citation Text:
Philipsen NC. The Criminalization of Mistakes in Nursing. J Nurs Pract. 2011;7(9):719-726. doi:10.1016/j.nurpra.2011.07.004.
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psnet.ahrq.gov/issue/improving-patient-safety-team-coordination-challenges-and-strategies-implementation
February 12, 2020 - Commentary
Improving patient safety with team coordination: challenges and strategies of implementation.
Citation Text:
Improving patient safety with team coordination: challenges and strategies of implementation. Harris KT; Treanor CM; Salisbury ML.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state-apc.html
January 01, 2024 - Current State of Diagnostic Safety: Implications for Research, Practice, and Policy
Appendix C. Interview Guide
Previous Page
Table of Contents
Current State of Diagnostic Safety: Implications for Research, Practice, and Policy
1. Introduction
2. Methods
3. Results
4. Discussion
Referenc…