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psnet.ahrq.gov/node/41369/psn-pdf
May 29, 2015 - Cognitive interventions to reduce diagnostic error: a
narrative review.
May 29, 2015
Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative
review. BMJ Qual Saf. 2012;21(7):535-557. doi:10.1136/bmjqs-2011-000149.
https://psnet.ahrq.gov/issue/cognitive-interventions-re…
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psnet.ahrq.gov/node/43904/psn-pdf
October 13, 2015 - Reducing unacceptable missed doses: pharmacy
assistant–supported medicine administration.
October 13, 2015
Baqir W, Jones K, Horsley W, et al. Reducing unacceptable missed doses: pharmacy assistant-supported
medicine administration. Int J Pharm Pract. 2015;23(5):327-332. doi:10.1111/ijpp.12172.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/72519/psn-pdf
December 02, 2020 - Evaluation of a patient-centered fall-prevention tool kit to
reduce falls and injuries: a nonrandomized controlled
trial.
December 2, 2020
Dykes PC, Burns Z, Adelman JS, et al. Evaluation of a patient-centered fall-prevention tool kit to reduce
falls and injuries: a nonrandomized controlled trial. JAMA Netw Open. …
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psnet.ahrq.gov/node/43378/psn-pdf
August 14, 2014 - Interventions to reduce pediatric medication errors: a
systematic review.
August 14, 2014
Rinke ML, Bundy DG, Velasquez CA, et al. Interventions to reduce pediatric medication errors: a
systematic review. Pediatrics. 2014;134(2):338-360. doi:10.1542/peds.2013-3531.
https://psnet.ahrq.gov/issue/interventions-reduce…
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psnet.ahrq.gov/node/40200/psn-pdf
July 02, 2014 - Checklists to reduce diagnostic errors.
July 2, 2014
Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med. 2011;86(3):307-313.
doi:10.1097/ACM.0b013e31820824cd.
https://psnet.ahrq.gov/issue/checklists-reduce-diagnostic-errors
Diagnostic errors are rapidly gaining attention as the next f…
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psnet.ahrq.gov/node/41619/psn-pdf
November 27, 2012 - A multicenter, phased, cluster-randomized controlled trial
to reduce central line–associated bloodstream infections
in intensive care units.
November 27, 2012
Marsteller JA, Sexton B, Hsu Y-J, et al. A multicenter, phased, cluster-randomized controlled trial to reduce
central line-associated bloodstream infections…
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psnet.ahrq.gov/node/47974/psn-pdf
May 08, 2019 - Reducing surgical mortality in Scotland by use of the
WHO Surgical Safety Checklist.
May 8, 2019
Ramsay G, Haynes AB, Lipsitz SR, et al. Reducing surgical mortality in Scotland by use of the WHO
Surgical Safety Checklist. Br J Surg. 2019;106(8):1005-1011. doi:10.1002/bjs.11151.
https://psnet.ahrq.gov/issue/reducin…
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psnet.ahrq.gov/node/40819/psn-pdf
January 07, 2015 - Multimodal system designed to reduce errors in recording
and administration of drugs in anaesthesia: prospective
randomised clinical evaluation.
January 7, 2015
Merry A, Webster CS, Hannam J, et al. Multimodal system designed to reduce errors in recording and
administration of drugs in anaesthesia: prospective ran…
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psnet.ahrq.gov/node/73130/psn-pdf
January 01, 2022 - Improving peripherally inserted central catheter
appropriateness and reducing device-related
complications: a quasiexperimental study in 52 Michigan
hospitals.
April 14, 2021
Chopra V, O'Malley M, Horowitz J, et al. Improving peripherally inserted central catheter appropriateness
and reducing device-related compl…
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psnet.ahrq.gov/node/837297/psn-pdf
June 01, 2022 - Checklists to reduce diagnostic error: a systematic review
of the literature using a human factors framework.
June 1, 2022
Al-Khafaji J, Townshend RF, Townsend W, et al. Checklists to reduce diagnostic error: a systematic review
of the literature using a human factors framework. BMJ Open. 2022;12(4):e058219. doi:10…
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psnet.ahrq.gov/node/45437/psn-pdf
September 01, 2018 - Decreasing malpractice claims by reducing preventable
perinatal harm.
September 1, 2018
Riley W, Meredith LW, Price R, et al. Decreasing Malpractice Claims by Reducing Preventable Perinatal
Harm. Health Serv Res. 2016;51(suppl 3):2453-2471. doi:10.1111/1475-6773.12551.
https://psnet.ahrq.gov/issue/decreasing-malpr…
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psnet.ahrq.gov/node/36047/psn-pdf
September 28, 2010 - When policy meets physiology: the challenge of reducing
resident work hours.
September 28, 2010
Lockley SW, Landrigan CP, Barger LK, et al. When policy meets physiology: the challenge of reducing
resident work hours. Clin Orthop Relat Res. 2006;449:116-127.
https://psnet.ahrq.gov/issue/when-policy-meets-physiology…
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psnet.ahrq.gov/node/42512/psn-pdf
August 21, 2013 - Project BOOST: effectiveness of a multihospital effort to
reduce rehospitalization.
August 21, 2013
Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: effectiveness of a multihospital effort to
reduce rehospitalization. J Hosp Med. 2013;8(8):421-7. doi:10.1002/jhm.2054.
https://psnet.ahrq.gov/issue/project-…
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psnet.ahrq.gov/node/36679/psn-pdf
December 21, 2009 - Manic for medication safety: bar codes and drug
information databases are helping to reduce medication
errors.
December 21, 2009
Rogoski RR. Manic for medication safety. Health management technology. 2007;28(2):14, 16-8.
https://psnet.ahrq.gov/issue/manic-medication-safety-bar-codes-and-drug-information-databases-…
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psnet.ahrq.gov/node/37125/psn-pdf
October 04, 2011 - Current pulse: can a production system reduce medical
errors in health care?
October 4, 2011
Printezis A, Gopalakrishnan M. Current pulse: can a production system reduce medical errors in health
care? Qual Manag Health Care. 2007;16(3):226-238.
https://psnet.ahrq.gov/issue/current-pulse-can-production-system-reduc…
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psnet.ahrq.gov/node/39326/psn-pdf
July 31, 2012 - Initiative to Reduce Unnecessary Radiation Exposure
from Medical Imaging.
July 31, 2012
Center for Devices and Radiological Health; CDRH; US Food and Drug Administration; FDA.
https://psnet.ahrq.gov/issue/initiative-reduce-unnecessary-radiation-exposure-medical-imaging
This Web site provides information on an init…
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www.ahrq.gov/patient-safety/settings/hospital/resource/transform.html
December 01, 2017 - Transforming Hospitals
Designing for Safety and Quality
Transforming Hospitals: Designing for Safety and Quality , a video from the Agency for Healthcare Research and Quality (AHRQ), reviews the case for evidence-based hospital design and how it increases patient and staff satisfaction and safety, quality of …
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psnet.ahrq.gov/node/36708/psn-pdf
April 21, 2011 - Missed breast cancers at US-guided core needle biopsy:
how to reduce them.
April 21, 2011
Youk JH, Kim E-K, Kim MJ, et al. Missed breast cancers at US-guided core needle biopsy: how to reduce
them. Radiographics. 2007;27(1):79-94.
https://psnet.ahrq.gov/issue/missed-breast-cancers-us-guided-core-needle-biopsy-how-…
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psnet.ahrq.gov/node/37840/psn-pdf
June 28, 2016 - Engaging Patients as Safety Partners: a Guide for
Reducing Errors and Improving Satisfaction.
June 28, 2016
Spath P, ed. Chicago, IL: AHA Press; 2008. ISBN: 9781556483530.
https://psnet.ahrq.gov/issue/engaging-patients-safety-partners-guide-reducing-errors-and-improving-
satisfaction
This book discusses strategie…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
December 01, 2017 - Example: You get the supply from another area or you manage without it
Second-order problem solving
Reduces