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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
January 01, 2004 - A Model-based Approach to Prioritizing Medical Safety Practices
409
A Model-based Approach to Prioritizing
Medical Safety Practices
Richard S. Marken
Abstract
This report shows how a model of skilled human performance can be used to
evaluate safety practices aimed at reducing medical error when randomized tr…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Stalhandske2_70.pdf
March 01, 2006 - VHA’s National Falls Collaborative and Prevention Programs
VHA’s National Falls Collaborative and
Prevention Programs
Erik Stalhandske, MPP, MHSA; Peter Mills, PhD; Pat Quigley, PhD, ARNP, CRRN, FAAN;
Julia Neily, MS, MPH; James P. Bagian, MD, PE
Abstract
Falls are a high-volume, high-cost problem in he…
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www.ahrq.gov/patient-safety/reports/healthaffairs.html
March 01, 2019 - AHRQ-Funded Patient Safety Research Featured in Health Affairs
AHRQ-funded research studies focused on critical aspects of patient safety and health information technology were published in a November 2018 patient safety-themed issue of Health Affairs . As part of its commitment to lead patient-safety efforts …
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections.html
May 01, 2017 - Toolkit Sections
Implementation
Implementation Guide : It may be helpful to review this guide before starting a project to reduce infections and other complications in your ambulatory surgery center. The guide takes users step by step through the execution of technical and cultural interventions surroundi…
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psnet.ahrq.gov/node/47367/psn-pdf
October 15, 2018 - Themed Issue on Innovations in Medication Safety.
October 15, 2018
Kane-Gill SL. Innovations in Medication Safety: Services and Technologies to Enhance the Understanding
and Prevention of Adverse Drug Reactions. Pharmacotherapy. 2018;38(8):782-784.
doi:10.1002/phar.2154.
https://psnet.ahrq.gov/issue/themed-issue-i…
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psnet.ahrq.gov/node/43751/psn-pdf
February 11, 2015 - Perceptions of time spent on safety tasks in surgical
operations: a focus group study.
February 11, 2015
Høyland S, Haugen AS, Thomassen Ø. Perceptions of time spent on safety tasks in surgical operations: A
focus group study. Saf Sci. 2014;70. doi:10.1016/j.ssci.2014.05.009.
https://psnet.ahrq.gov/issue/perceptio…
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psnet.ahrq.gov/node/46861/psn-pdf
February 28, 2018 - Special K with no license to kill: accidental ketamine
overdose on induction of general anesthesia.
February 28, 2018
Warner LL, Smischney N. Accidental Ketamine Overdose on Induction of General Anesthesia. Am J Case
Rep. 2018;19:10-12.
https://psnet.ahrq.gov/issue/special-k-no-license-kill-accidental-ketamine-ove…
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psnet.ahrq.gov/node/44536/psn-pdf
November 11, 2015 - Healthcare system intervention for safer use of medicines
in elderly patients in primary care—a qualitative study of
the participants' perceptions of self-assessment, peer
review, feedback and agreement for change.
November 11, 2015
Lenander C, Bondesson Å, Midlöv P, et al. Healthcare system intervention for safer…
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psnet.ahrq.gov/node/839831/psn-pdf
November 09, 2022 - A new category of "never events"-ending harmful hospital
policies.
November 9, 2022
Chokshi DA, Beckman AL. A new category of "never events"-ending harmful hospital policies. JAMA Health
Forum. 2022;3(10):e224703. doi:10.1001/jamahealthforum.2022.4703.
https://psnet.ahrq.gov/issue/new-category-never-events-ending-…
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psnet.ahrq.gov/node/47013/psn-pdf
April 07, 2019 - An electronic intervention to improve safety for pain
patients co-prescribed chronic opioids and
benzodiazepines.
April 7, 2019
Zaman T, Rife TL, Batki SL, et al. An electronic intervention to improve safety for pain patients co-
prescribed chronic opioids and benzodiazepines. Subst Abus. 2018;39(4):441-448.
doi:…
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psnet.ahrq.gov/node/44422/psn-pdf
November 17, 2017 - Stop the noise: a quality improvement project to decrease
electrocardiographic nuisance alarms.
November 17, 2017
Sendelbach S, Wahl S, Anthony A, et al. Stop the Noise: A Quality Improvement Project to Decrease
Electrocardiographic Nuisance Alarms. Crit Care Nurse. 2015;35(4):15-22; quiz 1p following 22.
doi:10.4…
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digital.ahrq.gov/health-care-theme/smoking-cessation
January 01, 2023 - Smoking Cessation
Reducing Hospital Readmission Rates by Implementing an Inpatient Tobacco Cessation Service Driven by Interactive Voice Recognition Technology
Description
This study evaluated a smoking cessation program using interactive voice recognition technology and found…
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psnet.ahrq.gov/node/837694/psn-pdf
July 20, 2022 - Implementing root cause analysis and action: integrating
human factors to create strong interventions and reduce
risk of patient harm.
July 20, 2022
Wolf L, Gorman K, Clark J, et al. Implementing root cause analysis and action: integrating human factors to
create strong interventions and reduce risk of patient har…
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digital.ahrq.gov/organization/wake-forest-university-health-sciences
January 01, 2023 - Wake Forest University Health Sciences
Digital EMS Point-of-Care Innovation to Improve Rural STEMI Outcomes
Description
This research will develop, implement, refine, and evaluate an app to support clinical decisions for ST-Elevation Myocardial Infarction care in rural areas b…
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digital.ahrq.gov/principal-investigator/mahler-simon
January 01, 2023 - Mahler, Simon A
Risk of delayed percutaneous coronary intervention for STEMI in the Southeast United States.
Citation
Messinger MC, Ashburn NP, Chait JS, Snavely AC, Hapig-Ward S, Stopyra JP, Mahler SA. Risk of delayed percutaneous coronary intervention for STEMI in the Southe…
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psnet.ahrq.gov/node/35977/psn-pdf
February 17, 2011 - Making patient safety the centerpiece of medical liability
reform.
February 17, 2011
Clinton HR, Obama B. Making Patient Safety the Centerpiece of Medical Liability Reform. New England
Journal of Medicine. 2006;354(21). doi:10.1056/nejmp068100.
https://psnet.ahrq.gov/issue/making-patient-safety-centerpiece-medical…
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psnet.ahrq.gov/node/47924/psn-pdf
June 05, 2019 - Effect of a central call center on employee perceptions of
safety culture within community pharmacies in an
academic health system.
June 5, 2019
Bowden A, Mullin S, Tak C, et al. Effect of a central call center on employee perceptions of safety culture
within community pharmacies in an academic health system. Am J…
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psnet.ahrq.gov/node/865929/psn-pdf
May 22, 2024 - Diagnostic stewardship to improve patient outcomes and
healthcare-associated infection (HAI) metrics.
May 22, 2024
Singh HK, Claeys KC, Advani SD, et al. Diagnostic stewardship to improve patient outcomes and
healthcare-associated infection (HAI) metrics. Infect Control Hosp Epidemiol. 2024;45(4):405-411.
doi:10.1…
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psnet.ahrq.gov/node/865480/psn-pdf
April 03, 2024 - A narrative review of the well-being and burnout of U.S.
community pharmacists.
April 3, 2024
Wash A, Moczygemba LR, Brown CM, et al. A narrative review of the well-being and burnout of U.S.
community pharmacists. J Am Pharm Assoc (2003). 2023;64(2):337-349. doi:10.1016/j.japh.2023.11.017.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/38330/psn-pdf
September 24, 2010 - Medication safety teams' guided implementation of
electronic medication administration records in five
nursing homes.
September 24, 2010
Scott-Cawiezell J, Madsen RW, Pepper GA, et al. Medication safety teams' guided implementation of
electronic medication administration records in five nursing homes. Jt Comm J Qu…