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psnet.ahrq.gov/node/45436/psn-pdf
August 31, 2016 - Improving the communication between teams managing
boarded patients on a surgical specialty ward.
August 31, 2016
Puvaneswaralingam S, Ross D. Improving the communication between teams managing boarded patients
on a surgical specialty ward. BMJ Qual Improv Rep. 2016;5(1). doi:10.1136/bmjquality.u209186.w3750.
http…
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psnet.ahrq.gov/node/47015/psn-pdf
May 09, 2018 - How DeKalb Medical fixed drug safety problems after fatal
error.
May 9, 2018
Porter S. HealthLeaders Media. April 26, 2018.
https://psnet.ahrq.gov/issue/how-dekalb-medical-fixed-drug-safety-problems-after-fatal-error
Overreliance on technology can result in harmful medication mistakes. Reporting on a 10-fold medic…
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psnet.ahrq.gov/node/60158/psn-pdf
March 25, 2020 - Identifying adverse events: reflections on an imperfect
gold standard after 20 years of patient safety research.
March 25, 2020
Shojania KG, Marang-van de Mheen PJ. Identifying adverse events: reflections on an imperfect gold
standard after 20 years of patient safety research. BMJ Qual Saf. 2020;29(4). doi:10.1136/…
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psnet.ahrq.gov/node/38799/psn-pdf
September 29, 2009 - Work-arounds and artifacts during transition to a
computer physician order entry: what they are and what
they mean.
September 29, 2009
Schoville RR. Work-arounds and artifacts during transition to a computer physician order entry: what they
are and what they mean. J Nurs Care Qual. 2009;24(4):316-324. doi:10.1097/…
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psnet.ahrq.gov/node/60957/psn-pdf
September 30, 2020 - A narrative review of strategies to increase patient safety
event reporting by residents.
September 30, 2020
Aaron M, Webb A, Luhanga U. A narrative review of strategies to increase patient safety event reporting by
residents. J Grad Med Educ. 2020;12(4):415-424. doi:10.4300/jgme-d-19-00649.1.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/850352/psn-pdf
June 14, 2023 - Stigmatizing language expressed towards individuals
with current or previous OUD who have pain and cancer:
a qualitative study.
June 14, 2023
Sedney CL, Dekeseredy P, Singh SA, et al. Stigmatizing language expressed towards individuals with
current or previous OUD who have pain and cancer: a qualitative study. J P…
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psnet.ahrq.gov/node/47224/psn-pdf
June 27, 2018 - Managing Alarms in Acute Care Across the Life Span:
Electrocardiography and Pulse Oximetry.
June 27, 2018
Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry. Crit Care
Nurse. 2018;38(2):e16-e20. doi:10.4037/ccn2018468.
https://psnet.ahrq.gov/issue/managing-alarms-acute-care-…
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psnet.ahrq.gov/node/60206/psn-pdf
April 08, 2020 - Reducing high-risk medication use through pharmacist-
led interventions in an outpatient setting.
April 8, 2020
Deyo JC, Smith BH, Biola H, et al. Reducing high-risk medication use through pharmacist-led interventions
in an outpatient setting. J Am Pharm Assoc. 2020. doi:10.1016/j.japh.2020.01.013.
https://psnet.a…
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psnet.ahrq.gov/node/36947/psn-pdf
September 09, 2011 - The safety of warfarin therapy in the nursing home
setting.
September 9, 2011
Gurwitz JH, Field T, Radford MJ, et al. The safety of warfarin therapy in the nursing home setting. Am J
Med. 2007;120(6):539-44.
https://psnet.ahrq.gov/issue/safety-warfarin-therapy-nursing-home-setting
The anticoagulant warfarin is co…
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psnet.ahrq.gov/node/44614/psn-pdf
November 04, 2015 - Components of hospital perioperative infrastructure can
overcome the weekend effect in urgent general surgery
procedures.
November 4, 2015
Kothari A, Zapf MAC, Blackwell RH, et al. Components of Hospital Perioperative Infrastructure Can
Overcome the Weekend Effect in Urgent General Surgery Procedures. Ann Surg. 20…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024983-pratap-final-report-2019.pdf
January 01, 2019 - Using the Electronic Health Record To Identify Children Likely To Suffer Last-Minute Surgery Cancellation - Final Report
Using the electronic health record to identify children likely to suffer last-minute surgery
cancellation
Principal Investigator: J. “Nick” Pratap, MB Chir, MRCPCH, FRCA1
Team…
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digital.ahrq.gov/sites/default/files/docs/publication/u18hs016970-bates-final-report-2012.pdf
January 01, 2012 - Health Information Technology and Improving Medication Use - Final Report
Program Director/Principal Investigator : Bates, David W
0925-0001/0002 (Rev. 08/12) Page 1 Continuation Format Page
Title of Project: Health Information Technology and Improving Medication Use
Principal Investigator and Team Membe…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-139-fullreport.pdf
May 01, 2017 - Transcranial Doppler Ultrasonography Screening Among Children With Sickle Cell Anemia
Transcranial Doppler Ultrasonography Screening
Among Children with Sickle Cell Anemia
Section 1. Basic Measure Information
1.A. Measure Name
Transcranial Doppler Ultrasonography Screening Among Children with Sickle Cell Anemia …
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www.ahrq.gov/sites/default/files/2025-03/taylor-report.pdf
January 01, 2025 - Final Progress Report: Disseminating a Web-Enabled Safety Risk Assessment (SRA) Toolkit for Designing Safer Healthcare Facilities
Final Report
1. Title Page
Principal Investigator: Ellen Taylor
Project Title: Disseminating a web-enabled Safety Risk Assessment (SRA) toolkit for designing safer
healthcare facilitie…
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digital.ahrq.gov/sites/default/files/docs/citation/r18hs026172-obrien-final-report-2022.pdf
January 01, 2022 - interventions.17 Semi-
structured provider interviews were conducted by a research coordinator and were recorded
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www.ahrq.gov/sites/default/files/2024-01/johnson-baughman-report.pdf
January 01, 2024 - , in phase 2, it became more challenging to ascertain
the extent to which all callbacks were being recorded
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017150-lapane-final-report-2010.pdf
January 01, 2010 - At baseline and
follow-up, we also requested that 5 clinical encounters per physician be audio recorded
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs022586-lacson-final-report-2017.pdf
January 01, 2017 - resulted in increased adherence to our critical result communication
policy.(3) ANCR notifications are recorded
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs024004-bajaj-final-report-2017.pdf
January 01, 2017 - Readmissions within 30 days were recorded via the App, with a thorough review of the record
and discussion
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psnet.ahrq.gov/web-mm/techno-trip
May 01, 2005 - Techno Trip
Citation Text:
Cook RI. Techno Trip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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