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psnet.ahrq.gov/issue/critical-care-safety-study-incidence-and-nature-adverse-events-and-serious-medical-errors
July 15, 2020 - Study
The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care.
Citation Text:
Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical e…
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psnet.ahrq.gov/issue/risk-factors-and-outcomes-foreign-body-left-during-procedure-analysis-413-incidents-after
December 04, 2016 - Study
Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1,946,831 operations in children.
Citation Text:
Camp M, Chang DC, Zhang Y, et al. Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after…
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psnet.ahrq.gov/issue/development-and-pilot-evaluation-electronic-health-record-usability-and-safety-self
December 21, 2022 - Study
Development and pilot evaluation of an electronic health record usability and safety self-assessment tool.
Citation Text:
Pruitt Z, Howe JL, Krevat S, et al. Development and pilot evaluation of an electronic health record usability and safety self-assessment tool. JAMIA Open. 2022;…
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psnet.ahrq.gov/issue/longitudinal-study-multifaceted-intervention-reduce-newborn-falls-while-preserving-rooming
March 20, 2019 - Study
A longitudinal study of a multifaceted intervention to reduce newborn falls while preserving rooming-in on a mother-baby unit.
Citation Text:
Whatley C, Schlogl J, Whalen BL, et al. A longitudinal study of a multifaceted intervention to reduce newborn falls while preserving rooming…
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psnet.ahrq.gov/issue/healing-our-own-randomized-trial-assess-benefits-peer-support
May 19, 2021 - Study
Healing our own: a randomized trial to assess benefits of peer support.
Citation Text:
Rivera-Chiauzzi EY, Smith HA, Moore-Murray T, et al. Healing our own: a randomized trial to assess benefits of peer support. J Patient Saf. 2022;18(1):e308-e314. doi:10.1097/pts.0000000000000771.…
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psnet.ahrq.gov/issue/organizational-cultural-and-psychological-determinants-smart-infusion-pump-work-arounds-study
May 18, 2022 - Study
Organizational, cultural, and psychological determinants of smart infusion pump work arounds: a study of 3 U.S. health systems.
Citation Text:
Dunford BB, Perrigino M, Tucker SJ, et al. Organizational, Cultural, and Psychological Determinants of Smart Infusion Pump Work Arounds: A …
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psnet.ahrq.gov/issue/critical-drug-drug-interactions-use-electronic-health-records-systems-computerized-physician
December 21, 2017 - Study
Critical drug–drug interactions for use in electronic health records systems with computerized physician order entry: review of leading approaches.
Citation Text:
Classen DC, Phansalkar S, Bates DW. Critical Drug-Drug Interactions for Use in Electronic Health Records Systems With…
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psnet.ahrq.gov/issue/walkrounds-practice-corrupting-or-enhancing-quality-improvement-intervention-qualitative
December 30, 2014 - Study
Walkrounds in practice: corrupting or enhancing a quality improvement intervention? A qualitative study.
Citation Text:
Martin G, Ozieranski P, Willars J, et al. Walkrounds in practice: corrupting or enhancing a quality improvement intervention? A qualitative study. Jt Comm J Qual …
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psnet.ahrq.gov/issue/electronic-prescribing-ambulatory-care-setting-cluster-randomized-trial
October 31, 2011 - Study
Electronic prescribing in an ambulatory care setting: a cluster randomized trial.
Citation Text:
Dainty KN, Adhikari NKJ, Kiss A, et al. Electronic prescribing in an ambulatory care setting: a cluster randomized trial. J Eval Clin Pract. 2012;18(4):761-7. doi:10.1111/j.1365-2753.…
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psnet.ahrq.gov/issue/health-care-cost-drug-related-morbidity-and-mortality-nursing-facilities
September 19, 2016 - Study
Classic
The health care cost of drug-related morbidity and mortality in nursing facilities.
Citation Text:
Bootman JL, Harrison DL, Cox E. The health care cost of drug-related morbidity and mortality in nursing facilities. Arch Intern Med. 1997;157(18):2…
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psnet.ahrq.gov/issue/benchmarking-surgical-incident-reports-using-database-and-triage-system-reduce-adverse
June 18, 2008 - Study
Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes.
Citation Text:
Antonacci AC, Lam S, Lavarias V, et al. Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes. Arch Sur…
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psnet.ahrq.gov/issue/effect-universal-glove-and-gown-use-adverse-events-intensive-care-unit-patients
December 09, 2015 - Study
The effect of universal glove and gown use on adverse events in intensive care unit patients.
Citation Text:
Croft LD, Harris AD, Pineles L, et al. The Effect of Universal Glove and Gown Use on Adverse Events in Intensive Care Unit Patients. Clin Infect Dis. 2015;61(4):545-53. doi:…
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psnet.ahrq.gov/issue/do-work-condition-interventions-affect-quality-and-errors-primary-care-results-healthy-work
September 04, 2016 - Study
Do work condition interventions affect quality and errors in primary care? Results from the Healthy Work Place Study.
Citation Text:
Linzer M, Poplau S, Brown RL, et al. Do Work Condition Interventions Affect Quality and Errors in Primary Care? Results from the Healthy Work Place S…
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psnet.ahrq.gov/issue/effect-pharmacist-email-alerts-concurrent-prescribing-opioids-and-benzodiazepines-prescribers
September 07, 2022 - Study
Effect of pharmacist email alerts on concurrent prescribing of opioids and benzodiazepines by prescribers and primary care managers: a randomized clinical trial.
Citation Text:
Sacarny A, Safran E, Steffel M, et al. Effect of pharmacist email alerts on concurrent prescribing of opi…
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psnet.ahrq.gov/issue/can-residents-detect-errors-technique-while-observing-central-line-insertions
April 12, 2019 - Study
Can residents detect errors in technique while observing central line insertions?
Citation Text:
Pei K, Merola J, Davis KA, et al. Can residents detect errors in technique while observing central line insertions? Am J Surg. 2017;213(6):1166-1170.e1. doi:10.1016/j.amjsurg.2016.08.02…
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psnet.ahrq.gov/issue/effects-reducing-or-eliminating-resident-work-shifts-over-16-hours-systematic-review
November 12, 2014 - Review
Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review.
Citation Text:
Levine AC, Adusumilli J, Landrigan CP. Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review. Sleep. 2010;33(8):1043-53. doi:10.1093/sl…
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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…
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psnet.ahrq.gov/issue/diagnosis-team-sport-partnering-allied-health-professionals-reduce-diagnostic-errors-case
July 28, 2023 - Study
Diagnosis is a team sport—partnering with allied health professionals to reduce diagnostic errors: a case study on the role of a vestibular therapist in diagnosing dizziness.
Citation Text:
Thomas DB, Newman-Toker DE. Diagnosis is a team sport - partnering with allied health profes…
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psnet.ahrq.gov/issue/soft-factors-smooth-transport-role-safety-climate-and-team-processes-reducing-adverse-events
September 27, 2016 - Commentary
Soft factors, smooth transport? The role of safety climate and team processes in reducing adverse events during intrahospital transport in intensive care.
Citation Text:
Latzke M, Schiffinger M, Zellhofer D, et al. Soft Factors, Smooth Transport? The role of safety climate and…
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psnet.ahrq.gov/issue/patient-activation-related-fall-prevention-multisite-study
February 01, 2023 - Study
Patient activation related to fall prevention: a multisite study
Citation Text:
Christiansen TL, Lipsitz S, Scanlan M, et al. Patient activation related to fall prevention: a multisite study . Jt Comm J Qual Patient Saf. 2020. doi:10.1016/j.jcjq.2019.11.010.
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