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psnet.ahrq.gov/issue/association-display-patient-photographs-electronic-health-record-wrong-patient-order-entry
May 29, 2019 - Study
Association of display of patient photographs in the electronic health record with wrong-patient order entry errors.
Citation Text:
Salmasian H, Blanchfield BB, Joyce K, et al. Association of display of patient photographs in the electronic health record with wrong-patient order e…
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psnet.ahrq.gov/issue/assessing-clinical-economic-and-health-resource-utilization-impacts-prefilled-syringes-versus
August 15, 2018 - Review
Assessing the clinical, economic, and health resource utilization impacts of prefilled syringes versus conventional medication administration methods: results from a systematic literature review.
Citation Text:
Benhamou D, Weiss M, Borms M, et al. Assessing the clinical, economic,…
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psnet.ahrq.gov/issue/morbidity-and-mortality-conference-adverse-event-surveillance-tool-paediatric-intensive-care
April 06, 2016 - Study
The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit.
Citation Text:
Cifra CL, Jones KL, Ascenzi J, et al. The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit. B…
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psnet.ahrq.gov/issue/multi-level-analysis-national-nursing-students-disclosure-patient-safety-concerns
April 28, 2021 - Study
Multi-level analysis of national nursing students' disclosure of patient safety concerns.
Citation Text:
Palese A, Gonella S, Grassetti L, et al. Multi-level analysis of national nursing students' disclosure of patient safety concerns. Med Educ. 2018;52(11):1156-1166. doi:10.1111/m…
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psnet.ahrq.gov/issue/perceptions-hospital-safety-climate-and-incidence-readmission
March 25, 2015 - Study
Perceptions of hospital safety climate and incidence of readmission.
Citation Text:
Hansen LO, Williams M, Singer SJ. Perceptions of hospital safety climate and incidence of readmission. Health Serv Res. 2011;46(2):596-616. doi:10.1111/j.1475-6773.2010.01204.x.
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psnet.ahrq.gov/issue/randomized-controlled-trial-pictogram-based-intervention-reduce-liquid-medication-dosing
June 04, 2014 - Study
Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children.
Citation Text:
Yin S, Dreyer BP, van Schaick L, et al. Randomized controlled trial of a pictogram-based intervention …
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psnet.ahrq.gov/issue/impact-computerized-physician-order-entry-system-compliance-prescription-accuracy
May 27, 2011 - Study
Impact of a computerized physician order entry system on compliance with prescription accuracy requirements.
Citation Text:
Mir C, Gadri A, Zelger GL, et al. Impact of a computerized physician order entry system on compliance with prescription accuracy requirements. Pharm World Sc…
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psnet.ahrq.gov/issue/hospital-organisation-management-and-structure-prevention-health-care-associated-infection
January 22, 2014 - Review
Hospital organisation, management, and structure for prevention of health-care-associated infection: a systematic review and expert consensus.
Citation Text:
Zingg W, Holmes A, Dettenkofer M, et al. Hospital organisation, management, and structure for prevention of health-care-ass…
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psnet.ahrq.gov/issue/effect-hospital-follow-appointment-clinical-event-outcomes-and-mortality
April 24, 2018 - Study
Effect of hospital follow-up appointment on clinical event outcomes and mortality.
Citation Text:
Grafft CA, McDonald FS, Ruud KL, et al. Effect of hospital follow-up appointment on clinical event outcomes and mortality. Arch Intern Med. 2010;170(11):955-60. doi:10.1001/archinternm…
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psnet.ahrq.gov/issue/risks-complications-attending-physicians-after-performing-nighttime-procedures
February 14, 2018 - Study
Classic
Risks of complications by attending physicians after performing nighttime procedures.
Citation Text:
Rothschild JM. Risks of Complications by Attending Physicians After Performing Nighttime Procedures. JAMA. 2009;302(14):1565-1572. doi:10.1001/ja…
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www.ahrq.gov/news/newsroom/case-studies/201520.html
July 01, 2015 - Wisconsin Critical Access Hospital Sees Big Results with AHRQ’s CUSP, RED and TeamSTEPPS®
Search All Impact Case Studies
July 2015
Amery Hospital & Clinic, a 25-bed acute care critical access hospital in rural Wisconsin, used AHRQ’s Comprehensive Unit-based Safety Program (CUSP) to reduce surgical site in…
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psnet.ahrq.gov/issue/extended-work-duration-and-risk-self-reported-percutaneous-injuries-interns
January 07, 2011 - Study
Extended work duration and the risk of self-reported percutaneous injuries in interns.
Citation Text:
Ayas N, Barger LK, Cade BE, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA. 2006;296(9):1055-62.
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psnet.ahrq.gov/issue/preoperative-briefing-operating-room-shared-cognition-teamwork-and-patient-safety
May 02, 2012 - Study
Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety.
Citation Text:
Einav Y, Gopher D, Kara I, et al. Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety. Chest. 2010;137(2):443-9. doi:10.1378/chest.08…
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psnet.ahrq.gov/issue/executive-summary-american-college-obstetricians-and-gynecologists-presidential-task-force
September 23, 2020 - Commentary
Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery.
Citation Text:
Erickson TB, Kirkpatrick DH, DeFrancesco MS, et al. Executi…
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psnet.ahrq.gov/issue/sbar-improves-nurse-physician-communication-and-reduces-unexpected-death-pre-and-post
November 21, 2018 - Study
SBAR improves nurse–physician communication and reduces unexpected death: a pre and post intervention study.
Citation Text:
De Meester K, Verspuy M, Monsieurs KG, et al. SBAR improves nurse-physician communication and reduces unexpected death: a pre and post intervention study. Re…
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psnet.ahrq.gov/issue/are-language-barriers-associated-serious-medical-events-hospitalized-pediatric-patients
November 16, 2022 - Study
Classic
Are language barriers associated with serious medical events in hospitalized pediatric patients?
Citation Text:
Cohen AL. Are Language Barriers Associated With Serious Medical Events in Hospitalized Pediatric Patients? Pediatrics. 2005;116(3):575…
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psnet.ahrq.gov/issue/long-term-impacts-faced-patients-and-families-after-harmful-healthcare-events
December 01, 2021 - Study
Long-term impacts faced by patients and families after harmful healthcare events.
Citation Text:
Ottosen MJ, Sedlock E, Aigbe AO, et al. Long-term impacts faced by patients and families after harmful healthcare events. J Patient Saf. 2021;17(8):e1145-e1151. doi:10.1097/pts.00000000…
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psnet.ahrq.gov/issue/potential-artificial-intelligence-improve-patient-safety-scoping-review
March 09, 2022 - Review
Classic
The potential of artificial intelligence to improve patient safety: a scoping review.
Citation Text:
Bates DW, Levine DM, Syrowatka A, et al. The potential of artificial intelligence to improve patient safety: a scoping review. NPJ Digit Med. 2021…
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psnet.ahrq.gov/issue/inpatient-suicide-and-suicide-attempts-veterans-affairs-hospitals
January 02, 2017 - Study
Inpatient suicide and suicide attempts in Veterans Affairs hospitals.
Citation Text:
Mills PD, DeRosier JM, Ballot BA, et al. Inpatient suicide and suicide attempts in Veterans Affairs hospitals. Jt Comm J Qual Patient Saf. 2008;34(8):482-488.
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psnet.ahrq.gov/issue/elimination-central-venous-catheter-related-bloodstream-infections-intensive-care-unit
January 11, 2017 - Study
Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit.
Citation Text:
Longmate AG, Ellis KS, Boyle L, et al. Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit. BMJ Qual Saf. 2011;20(2):1…