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psnet.ahrq.gov/issue/high-reliability-health-care-getting-there-here
January 23, 2012 - Study
Classic
High-reliability health care: getting there from here.
Citation Text:
Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91(3):459-490. doi:10.1111/1468-0009.12023.
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psnet.ahrq.gov/issue/safety-inpatient-health-care
May 15, 2024 - Study
The safety of inpatient health care.
Citation Text:
Bates DW, Levine DM, Salmasian H, et al. The safety of inpatient health care. New Engl J Med. 2023;388(2):142-153. doi:10.1056/nejmsa2206117.
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psnet.ahrq.gov/issue/measurement-patient-safety-systematic-review-reliability-and-validity-adverse-event-detection
November 16, 2016 - Review
Measurement of patient safety: a systematic review of the reliability and validity of adverse event detection with record review.
Citation Text:
Hanskamp-Sebregts M, Zegers M, Vincent CA, et al. Measurement of patient safety: a systematic review of the reliability and validity of …
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psnet.ahrq.gov/issue/engaging-patients-vigilant-partners-safety-systematic-review
February 06, 2019 - Review
Classic
Engaging patients as vigilant partners in safety: a systematic review.
Citation Text:
Schwappach DLB. Engaging patients as vigilant partners in safety: a systematic review. Med Care Res Rev. 2010;67(2):119-148. doi:10.1177/1077558709342254.
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psnet.ahrq.gov/issue/patient-safety-resident-education-and-resident-well-being-following-implementation-2003-acgme
June 20, 2012 - Review
Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules.
Citation Text:
Fletcher KE, Reed DA, Arora V. Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rule…
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psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-preventable-complications
January 22, 2014 - Commentary
Classic
The wisdom and justice of not paying for "preventable complications."
Citation Text:
Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.1…
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psnet.ahrq.gov/issue/shift-change-handovers-and-subsequent-interruptions-potential-impacts-quality-care
February 04, 2009 - Study
Shift change handovers and subsequent interruptions: potential impacts on quality of care.
Citation Text:
Estryn-Behar MR, Milanini-Magny G, Chaumon E, et al. Shift change handovers and subsequent interruptions: potential impacts on quality of care. J Patient Saf. 2014;10(1):29-44.…
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psnet.ahrq.gov/issue/quality-handoffs-community-pharmacies
May 11, 2016 - Study
Quality of handoffs in community pharmacies.
Citation Text:
Abebe E, Stone JA, Lester CA, et al. Quality of Handoffs in Community Pharmacies. J Patient Saf. 2021;17(6):405-411. doi:10.1097/PTS.0000000000000382.
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psnet.ahrq.gov/issue/caregiver-and-clinician-perspectives-discharge-medication-counseling-qualitative-study
January 31, 2024 - Study
Caregiver and clinician perspectives on discharge medication counseling: a qualitative study.
Citation Text:
Carroll AR, Schlundt D, Bonnet K, et al. Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. Hosp Pediatr. 2023;13(4):325-342. doi:…
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www.ahrq.gov/news/newsroom/case-studies/cquips0802.html
October 01, 2014 - AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors in Emergency Departments
Search All Impact Case Studies
June 2008
AHRQ-sponsored research on how clinical pharmacy services can reduce medication-related errors in hospital emergency departments has been put to use in hospitals in a …
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psnet.ahrq.gov/issue/identification-latent-safety-threats-using-high-fidelity-simulation-based-training
June 26, 2019 - Study
Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary neonatology teams.
Citation Text:
Wetzel EA, Lang TR, Pendergrass TL, et al. Identification of Latent Safety Threats Using High-Fidelity Simulation-Based Training with Mult…
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psnet.ahrq.gov/issue/minor-flow-disruptions-traffic-related-factors-and-their-effect-major-flow-disruptions
August 19, 2020 - Study
Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room.
Citation Text:
Joseph A, Khoshkenar A, Taaffe KM, et al. Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating roo…
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psnet.ahrq.gov/issue/parents-understanding-medication-discharge-and-potential-harm-children-medical-complexity
April 22, 2020 - Study
Parents' understanding of medication at discharge and potential harm in children with medical complexity.
Citation Text:
Selzer A, Eibensteiner F, Kaltenegger L, et al. Parents’ understanding of medication at discharge and potential harm in children with medical complexity. Arch Di…
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psnet.ahrq.gov/issue/hospital-testing-effectiveness-co-designed-educational-materials-improve-patient-and-visitor
February 28, 2024 - Study
Hospital testing of the effectiveness of co-designed educational materials to improve patient and visitor knowledge and confidence in reporting patient deterioration.
Citation Text:
King L, Belan I, Clark RA, et al. Hospital testing of the effectiveness of co-designed educational m…
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psnet.ahrq.gov/issue/impact-laws-aimed-healthcare-associated-infection-reduction-qualitative-study
December 23, 2020 - Study
Impact of laws aimed at healthcare-associated infection reduction: a qualitative study.
Citation Text:
Stone PW, Pogorzelska-Maziarz M, Reagan J, et al. Impact of laws aimed at healthcare-associated infection reduction: a qualitative study. BMJ Qual Saf. 2015;24(10):637-44. doi:10.…
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psnet.ahrq.gov/issue/relationship-nursing-practice-environment-quality-care-and-patients-safety-primary-health
March 09, 2022 - Study
Relationship of the nursing practice environment with the quality of care and patients' safety in primary health care.
Citation Text:
Lucas P, Jesus É, Almeida S, et al. Relationship of the nursing practice environment with the quality of care and patients’ safety in primary health…
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psnet.ahrq.gov/issue/perfect-storm-exam-medical-error-and-factors-contributing-its-possible-escalation
October 20, 2021 - Commentary
The perfect storm: exam of a medical error and factors contributing to its possible escalation.
Citation Text:
Walters GK. The perfect storm: exam of a medical error and factors contributing to its possible escalation. J Patient Saf. 2021;17(4):e264-e267. doi:10.1097/pts.00000…
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psnet.ahrq.gov/issue/evaluation-electronic-health-record-implementation-pharmacist-interventions-related-oral
January 25, 2023 - Study
Evaluation of electronic health record implementation on pharmacist interventions related to oral chemotherapy management.
Citation Text:
Finn A, Bondarenka C, Edwards K, et al. Evaluation of electronic health record implementation on pharmacist interventions related to oral chemot…
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psnet.ahrq.gov/issue/american-college-surgeons-committee-trauma-performance-improvement-and-patient-safety-program
September 23, 2020 - Study
American College of Surgeons' Committee on Trauma performance improvement and patient safety program: maximal impact in a mature trauma center.
Citation Text:
Sarkar B, Brunsvold ME, Cherry-Bukoweic JR, et al. American College of Surgeons' Committee on Trauma Performance Improvem…
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psnet.ahrq.gov/issue/society-maternal-fetal-medicine-special-statement-cognitive-bias-and-medical-error-obstetrics
May 18, 2022 - Organizational Policy/Guidelines
Society for Maternal-Fetal Medicine Special Statement: cognitive bias and medical error in obstetrics-challenges and opportunities.
Citation Text:
Atallah F, Hamm RF, Davidson CM, et al. Society for Maternal-Fetal Medicine Special Statement: Cognitive bia…