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9161. Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. | PSNet
      psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome-human-error
      December 09, 2020 - Study Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. Citation Text: Hensley NB, Koch CG, Pronovost P, et al. Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Int…

9162. Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital. | PSNet
      psnet.ahrq.gov/issue/demonstrating-high-reliability-accountability-measures-johns-hopkins-hospital
      January 27, 2016 - Study Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital. Citation Text: Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531…

9163. Evaluation of AHRQ's On-time Pressure Ulcer Program | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/evaluation-ahrqs-time-pressure-ulcer-program
      January 01, 2023 - Evaluation of AHRQ's On-time Pressure Ulcer Program Project Description Annual Summaries Publications Project Details - Completed Contract Number 290-06-0011-8 Funding Mechanism(s) Accelerating Change and Transformation in O…

9164. Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program. | PSNet
      psnet.ahrq.gov/issue/cost-inpatient-falls-and-cost-benefit-analysis-implementation-evidence-based-fall-prevention
      December 02, 2020 - Study Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program. Citation Text: Dykes PC, Curtin-Bowen M, Lipsitz S, et al. Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention prog…

9165. Thomas, Eric | Digital Healthcare Research
      digital.ahrq.gov/principal-investigator/thomas-eric
      January 01, 2023 - Thomas, Eric A time-motion study of registered nurses' workflow in intensive care unit remote monitoring. Citation Tang Z, Mazabob L, Weavind E, et al. A time-motion study of registered nurses' workflow in intensive care unit remote monitoring. AMIA Annu Symp Proc 2006:759-63.…

9166. Adverse events in long-term care residents transitioning from hospital back to nursing home. | PSNet
      psnet.ahrq.gov/issue/adverse-events-long-term-care-residents-transitioning-hospital-back-nursing-home
      April 28, 2021 - Study Adverse events in long-term care residents transitioning from hospital back to nursing home. Citation Text: Kapoor A, Field T, Handler S, et al. Adverse Events in Long-term Care Residents Transitioning From Hospital Back to Nursing Home. JAMA Intern Med. 2019;179(9):1254-1261. doi:…

9167. Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries and medication administration errors: an integrative review. | PSNet
      psnet.ahrq.gov/issue/shift-shift-nursing-handover-interventions-associated-improved-inpatient-outcomes-falls
      July 07, 2021 - Review Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries and medication administration errors: an integrative review. Citation Text: Hada A, Coyer F. Shift‐to‐shift nursing handover interventions associated with improved …

9168. Medication reconciliation in the geriatric unit: impact on the maintenance of post-hospitalization prescriptions. | PSNet
      psnet.ahrq.gov/issue/medication-reconciliation-geriatric-unit-impact-maintenance-post-hospitalization
      December 01, 2021 - Study Medication reconciliation in the geriatric unit: impact on the maintenance of post-hospitalization prescriptions. Citation Text: Montaleytang M, Correard F, Spiteri C, et al. Medication reconciliation in the geriatric unit: impact on the maintenance of post-hospitalization prescrip…

9169. What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports. | PSNet
      psnet.ahrq.gov/issue/what-can-we-learn-depth-analysis-human-errors-resulting-diagnostic-errors-emergency
      June 08, 2022 - Study What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports. Citation Text: Baartmans MC, Hooftman J, Zwaan L, et al. What can we learn from in-depth analysis of human errors resul…

9170. Patient-Centered Medical Home Information Model | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/patient-centered-medical-home-information-model
      January 01, 2023 - Patient-Centered Medical Home Information Model Project Final Report ( PDF , 1.5 MB) × Disclaimer Disclaimer details Close Project Description Annual Summaries Publications Project Details - Completed …

9171. A systematic review of the literature on the evaluation of handoff tools: implications for research and practice. | PSNet
      psnet.ahrq.gov/issue/systematic-review-literature-evaluation-handoff-tools-implications-research-and-practice
      May 23, 2012 - Review A systematic review of the literature on the evaluation of handoff tools: implications for research and practice. Citation Text: Abraham J, Kannampallil TG, Patel VL. A systematic review of the literature on the evaluation of handoff tools: implications for research and practice. …

9172. Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle. | PSNet
      psnet.ahrq.gov/issue/decreased-incidence-cesarean-surgical-site-infection-rate-hospital-wide-perioperative-bundle
      September 08, 2021 - Study Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle. Citation Text: Sood N, Lee RE, To JK, et al. Decreased incidence of cesarean surgical site infection rate with hospital‐wide perioperative bundle. Birth. 2022;49(1):141-146. doi:10…

9173. TRIAD IX: can a patient testimonial safely help ensure prehospital appropriate critical versus end-of-life care? | PSNet
      psnet.ahrq.gov/issue/triad-ix-can-patient-testimonial-safely-help-ensure-prehospital-appropriate-critical-versus
      April 03, 2017 - Study TRIAD IX: can a patient testimonial safely help ensure prehospital appropriate critical versus end-of-life care? Citation Text: Mirarchi FL, Cammarata C, Cooney TE, et al. TRIAD IX: can a patient testimonial safely help ensure prehospital appropriate critical versus end-of-life car…

9174. Improving Post-Hospital Medication Management of Older Adults with Health Information Technology - 2010 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/improving-post-hospital-medication-management-older-adults-health-information/annual-summary/2010
      January 01, 2010 - Improving Post-Hospital Medication Management of Older Adults with Health Information Technology - 2010 Project Name Improving Post-Hospital Medication Management of Older Adults with Health Information Technology Principal Investigator Gurwitz, Jerry Organization University …

9175. Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology. | PSNet
      psnet.ahrq.gov/issue/resilience-vs-vulnerability-psychological-safety-and-reporting-near-misses-varying-proximity
      December 16, 2020 - Study Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology. Citation Text: Jung OS, Kundu P, Edmondson AC, et al. Resilience vs. vulnerability: psychological safety and reporting of near misses with varying p…

9176. Interventions to reduce burnout and improve resilience: impact on a health system's outcomes. | PSNet
      psnet.ahrq.gov/issue/interventions-reduce-burnout-and-improve-resilience-impact-health-systems-outcomes
      January 10, 2018 - Study Interventions to reduce burnout and improve resilience: impact on a health system's outcomes. Citation Text: Moffatt-Bruce SD, Nguyen MC, Steinberg B, et al. Interventions to Reduce Burnout and Improve Resilience: Impact on a Health System's Outcomes. Clin Obstet Gynecol. 2019;62(3…

9177. Healthy Teens TXT ME: Information Technology to Change Teen Health Risk Behaviors | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/healthy-teens-txt-me-information-technology-change-teen-health-risk-behaviors
      January 01, 2023 - Healthy Teens TXT ME: Information Technology to Change Teen Health Risk Behaviors Project Final Report ( PDF , 243.68 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 necessarily …

9178. Toolkit 3. The Nursing Home Antibiogram Program Toolkit: How To Develop and Implement an Antibiogram Program | Agency for Healthcare Research and Quality
      www.ahrq.gov/nhguide/toolkits/help-clinicians-choose-the-right-antibiotic/toolkit3-develop-implement-antibiogram-program.html
      November 01, 2016 - Toolkit 3. The Nursing Home Antibiogram Program Toolkit: How To Develop and Implement an Antibiogram Program Toolkit Effectiveness This toolkit reflects the results of preliminary work with three nursing homes to develop the antibiogram, train staff, and implement the program. 1 Overview of the Toolkit Wh…

9179. Physician Engagement (Slide Presentation) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/phys-engagement/slides.html
      June 01, 2013 - Physician Engagement (Slide Presentation) On the CUSP: Stop BSI This PowerPoint slide presentation was shown on September 13, 2011. Contents Slide 1. Physician Engagement Slide 2. Image Slide 3. Learning Objectives Slide 4. What Do We Mean by Engagement? Slide 5. Where Does Engagement Fit? Slide…

9180. Project Report - Lean Sigma (ppt file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/twomorees-slides/Two-More-Es-and-How-to-Spread-Dec-13-2011-508.ppt
      January 01, 2011 - Project Report - Lean Sigma Two More E’s and How to Spread Learning Objectives To think ahead about ways to make your investment of time and improvements in BSI rates last forever To make sure all patients in your institution have access to the same level of safety in their care Implementation Framework Al…