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psnet.ahrq.gov/issue/implementing-handoff-communication
August 25, 2010 - Commentary
Implementing handoff communication.
Citation Text:
Ardoin KB, Broussard L. Implementing handoff communication. J Nurses Staff Dev. 2011;27(3):128-35. doi:10.1097/NND.0b013e318217b3dd.
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psnet.ahrq.gov/issue/clinical-care-checklists-salvations-or-frustrations
September 01, 2018 - Commentary
Clinical care checklists: salvations or frustrations?
Citation Text:
Jones JW, McCullough LB. Clinical care checklists: salvations or frustrations? J Vasc Surg. 2011;53(5):1429-30. doi:10.1016/j.jvs.2011.02.024.
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psnet.ahrq.gov/issue/how-use-article-about-quality-improvement
August 03, 2010 - Commentary
How to use an article about quality improvement.
Citation Text:
Fan E, Laupacis A, Pronovost P, et al. How to use an article about quality improvement. JAMA. 2010;304(20):2279-87. doi:10.1001/jama.2010.1692.
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psnet.ahrq.gov/issue/preventing-patient-harms-through-systems-care
February 27, 2014 - Study
Preventing patient harms through systems of care.
Citation Text:
Pronovost P, Bo-Linn GW. Preventing patient harms through systems of care. JAMA. 2012;308(8):769-70. doi:10.1001/jama.2012.9537.
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psnet.ahrq.gov/issue/mitigating-error-vulnerability-transition-care-through-use-health-it-applications
January 23, 2019 - Commentary
Mitigating error vulnerability at the transition of care through the use of health IT applications.
Citation Text:
Cortelyou-Ward K, Swain A, Yeung T. Mitigating Error Vulnerability at the Transition of Care through the Use of Health IT Applications. J Med Syst. 2012;36(6). d…
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psnet.ahrq.gov/issue/assessing-quality-patient-handoffs-care-transitions
April 24, 2013 - Study
Assessing the quality of patient handoffs at care transitions.
Citation Text:
Manser T, Foster S, Gisin S, et al. Assessing the quality of patient handoffs at care transitions. Qual Saf Health Care. 2010;19(6):e44. doi:10.1136/qshc.2009.038430.
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psnet.ahrq.gov/issue/journal-reporting-medical-errors-wisdom-solomon-bravery-achilles-and-foolishness-pan
April 24, 2018 - Review
Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan.
Citation Text:
Murphy JG, Stee LA, McEvoy MT, et al. Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan. Ch…
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psnet.ahrq.gov/issue/informatics-confronts-drug-drug-interactions
February 18, 2011 - Review
Informatics confronts drug–drug interactions.
Citation Text:
Percha B, Altman RB. Informatics confronts drug-drug interactions. Trends Pharmacol Sci. 2013;34(3):178-84. doi:10.1016/j.tips.2013.01.006.
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psnet.ahrq.gov/issue/labeling-solutions-and-medications-sterile-procedural-settings
July 13, 2016 - Commentary
Labeling solutions and medications in sterile procedural settings.
Citation Text:
Sheridan DJ. Labeling solutions and medications in sterile procedural settings. Jt Comm J Qual Patient Saf. 2006;32(5):276-82.
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psnet.ahrq.gov/issue/medication-errors-and-patient-complications-continuous-renal-replacement-therapy
June 25, 2009 - Study
Medication errors and patient complications with continuous renal replacement therapy.
Citation Text:
Barletta JF, Barletta G-M, Brophy PD, et al. Medication errors and patient complications with continuous renal replacement therapy. Pediatr Nephrol. 2006;21(6):842-5.
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psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-trade-offs
November 04, 2020 - Commentary
Scandal as a sentinel event—recognizing hidden cost–quality trade-offs.
Citation Text:
Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med. 2016;374(11):1001-3. doi:10.1056/NEJMp1502629.
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psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning
October 19, 2022 - Commentary
Preparing challenging medications for barcode scanning.
Citation Text:
Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm. 2015;72(13):1089-90. doi:10.2146/ajhp140454.
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psnet.ahrq.gov/issue/trainees-voice-recognising-importance-preoperative-briefings-surgical-trainees
October 09, 2019 - Commentary
The trainee's voice: recognising the importance of preoperative briefings for surgical trainees.
Citation Text:
Bethune R, Blencowe NS. The trainee's voice: recognising the importance of preoperative briefings for surgical trainees. J Perioper Pract. 2014;24(3):56-58.
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psnet.ahrq.gov/issue/survey-results-smart-pump-data-analytics-pump-metrics-should-be-monitored-improve-safety
August 08, 2018 - Newspaper/Magazine Article
Survey results: smart pump data analytics pump metrics that should be monitored to improve safety.
Citation Text:
Survey results: smart pump data analytics pump metrics that should be monitored to improve safety. ISMP Medication Safety Alert! Acute care edition…
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psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care
August 04, 2021 - Commentary
Classic
Continuous improvement as an ideal in health care.
Citation Text:
Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56.
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www.ahrq.gov/news/newsroom/case-studies/201809.html
January 01, 2019 - AHRQ Toolkit Helped NorthShore Health Track Data to Keep Infection Rates Low
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January 2019
Chicago’s NorthShore University Health System was on a mission to maintain low rates of catheter-associated urinary tract infections (CAUTI). Then NorthShore infection preventionist Mona …
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www.ahrq.gov/news/newsroom/case-studies/201526.html
January 01, 2018 - Iowa’s Waverly Health Center Uses AHRQ Tools to Improve Patient Safety
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September 2015
Waverly Health Center, a critical access hospital in Waverly, Iowa, has used three AHRQ resources to improve communication, teamwork, and leadership engagement as part of ongoing efforts to i…
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psnet.ahrq.gov/issue/voluntary-incident-reporting-anaesthetic-trainees-australian-hospital
August 17, 2005 - Study
Voluntary incident reporting by anaesthetic trainees in an Australian hospital.
Citation Text:
Freestone L, Bolsin S, Colson M, et al. Voluntary incident reporting by anaesthetic trainees in an Australian hospital. Int J Qual Health Care. 2006;18(6):452-7.
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digital.ahrq.gov/ahrq-funded-projects/artificial-intelligence-and-human-factors-healthcare-quality-safety
September 30, 2024 - Artificial Intelligence and Human Factors in Healthcare Quality & Safety
Project Description
By bringing together experts from academia, industry, and clinical practice to integrate human factors engineering (HFE) into artificial intelligence (AI) implementation and usage, this…
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psnet.ahrq.gov/issue/health-information-technology-related-wrong-patient-errors-context-critical
June 01, 2022 - Study
Health information technology-related wrong-patient errors: context is critical.
Citation Text:
Health information technology-related wrong-patient errors: context is critical. Kim T, Howe J, Franklin E, et al. Patient Safety. 2020;2(4):40–57.
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