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psnet.ahrq.gov/issue/science-interruption
September 04, 2024 - Commentary
The science of interruption.
Citation Text:
Coiera E. The science of interruption. BMJ Qual Saf. 2012;21(5):357-60. doi:10.1136/bmjqs-2012-000783.
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psnet.ahrq.gov/issue/diversion-threat-patient-safety-adopting-best-practices
April 20, 2022 - Webinar
Diversion is a Threat to Patient Safety: Adopting Best Practices.
Citation Text:
Diversion is a Threat to Patient Safety: Adopting Best Practices. Institute for Safe Medication Practices. April 6, 2022.
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psnet.ahrq.gov/node/40674/psn-pdf
October 16, 2012 - The care transitions intervention: translating from
efficacy to effectiveness.
October 16, 2012
Voss R, Gardner R, Baier R, et al. The care transitions intervention: translating from efficacy to
effectiveness. Arch Intern Med. 2011;171(14):1232-7. doi:10.1001/archinternmed.2011.278.
https://psnet.ahrq.gov/issue/ca…
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psnet.ahrq.gov/node/39670/psn-pdf
July 07, 2010 - The Power of Safety: State Reporting Provides Lessons in
Reducing Harm, Improving Care.
July 7, 2010
Washington DC: National Quality Forum; 2010.
https://psnet.ahrq.gov/issue/power-safety-state-reporting-provides-lessons-reducing-harm-improving-care
The landmark Institute of Medicine (IOM) report, To Err Is Human,…
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psnet.ahrq.gov/node/45585/psn-pdf
June 29, 2017 - Impact of Medicare's nonpayment program on hospital-
acquired conditions.
June 29, 2017
Thirukumaran CP, Glance LG, Temkin-Greener H, et al. Impact of Medicare's Nonpayment Program on
Hospital-acquired Conditions. Med Care. 2017;55(5):447-455. doi:10.1097/MLR.0000000000000680.
https://psnet.ahrq.gov/issue/impact-m…
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psnet.ahrq.gov/node/36255/psn-pdf
February 02, 2011 - Interns' compliance with Accreditation Council for
Graduate Medical Education work-hour limits.
February 2, 2011
Landrigan CP, Barger LK, Cade BE, et al. Interns' compliance with accreditation council for graduate
medical education work-hour limits. JAMA. 2006;296(9):1063-70.
https://psnet.ahrq.gov/issue/interns-c…
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psnet.ahrq.gov/node/837729/psn-pdf
July 27, 2022 - Development of a multicomponent intervention to
decrease racial bias among healthcare staff.
July 27, 2022
Tajeu GS, Juarez L, Williams JH, et al. Development of a multicomponent intervention to decrease racial
bias among healthcare staff. J Gen Intern Med. 2022;37(8):1970-1979. doi:10.1007/s11606-022-07464-x.
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psnet.ahrq.gov/node/866993/psn-pdf
October 30, 2024 - has gained a lot of steam in recent years because we have strong
evidence that naloxone saturation reduces
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psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
June 29, 2020 - Annual Perspective
Pharmacist Role in Patient Safety
February 21, 2020
View more articles from the same authors.
Citation Text:
Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
September 01, 2016 - PowerPoint Presentation
Spotlight
A Pill Organizing Plight
*
Source and Credits
This presentation is based on the September 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Ro…
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psnet.ahrq.gov/node/61071/psn-pdf
January 01, 2021 - Changes in early high-risk opioid prescribing practices
after policy interventions in Washington State.
October 28, 2020
Sears JM, Haight JR, Fulton?Kehoe D, et al. Changes in early high?risk opioid prescribing practices after
policy interventions in Washington State. Health Serv Res. 2021;56(1):49-60. doi:10.1111/…
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psnet.ahrq.gov/node/36979/psn-pdf
February 28, 2011 - Changes in outcomes for internal medicine inpatients
after work-hour regulations.
February 28, 2011
Horwitz LI, Kosiborod M, Lin Z, et al. Changes in outcomes for internal medicine inpatients after work-hour
regulations. Ann Intern Med. 2007;147(2):97-103.
https://psnet.ahrq.gov/issue/changes-outcomes-internal-med…
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psnet.ahrq.gov/issue/gossypiboma-tales-lost-sponges-and-lessons-learned
March 24, 2021 - Study
Gossypiboma: tales of lost sponges and lessons learned.
Citation Text:
McIntyre LK. Gossypiboma. Archives of Surgery. 2010;145(8). doi:10.1001/archsurg.2010.152.
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psnet.ahrq.gov/issue/applying-toyota-production-system-using-patient-safety-alert-system-reduce-error
June 21, 2015 - Commentary
Applying the Toyota Production System: using a patient safety alert system to reduce error.
Citation Text:
Furman C, Caplan RA. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007;33(7):376-386.
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psnet.ahrq.gov/issue/economics-patient-safety-strengthening-value-based-approach-reducing-patient-harm-national
May 02, 2018 - Book/Report
The Economics of Patient Safety: Strengthening a Value-based Approach to Reducing Patient Harm at National Level.
Citation Text:
The Economics of Patient Safety: Strengthening a Value-based Approach to Reducing Patient Harm at National Level. Slawomirski L, Auraaen A, Klazing…
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psnet.ahrq.gov/issue/partnership-patients-pfp-hospital-engagement-network-hen-20-final-report
May 06, 2015 - Book/Report
Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 Final Report.
Citation Text:
Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 Final Report. Chicago, IL: American Hospital Association and Health Research & Educational Trust; September 2…
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psnet.ahrq.gov/issue/toolkit-preventing-clabsi-and-cauti-icus
December 24, 2008 - Toolkit
Toolkit for Preventing CLABSI and CAUTI in ICUs.
Citation Text:
Toolkit for Preventing CLABSI and CAUTI in ICUs. Rockville, MD: Agency for Healthcare Research and Quality; April 2022.
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psnet.ahrq.gov/issue/overconfidence-cause-diagnostic-error-medicine
July 30, 2014 - Review
Overconfidence as a cause of diagnostic error in medicine.
Citation Text:
Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5 Suppl):S2-S23. doi:10.1016/j.amjmed.2008.01.001.
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psnet.ahrq.gov/issue/potentially-preventable-readmissions-conceptual-framework-rethink-role-primary-care-executive
November 01, 2016 - Book/Report
Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care. Executive Summary.
Citation Text:
Maxwell J, Bourgoin A, Crandall J. Potentially Preventable Readmissions: Conceptual Framework To Rethink The Role Of Primary Care. Executive Summa…
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psnet.ahrq.gov/issue/new-frontier-healthcare-risk-management-working-reduce-avoidable-patient-suffering
September 26, 2012 - Commentary
A new frontier in healthcare risk management: working to reduce avoidable patient suffering.
Citation Text:
Card AJ, Klein VR. A new frontier in healthcare risk management: Working to reduce avoidable patient suffering. J Healthc Risk Manag. 2016;35(3):31-7. doi:10.1002/jhrm.2…