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psnet.ahrq.gov/issue/impact-traditional-and-smart-pump-infusion-technology-nurse-medication-administration
May 18, 2022 - Study
The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.
Citation Text:
Trbovich PL, Pinkney S, Cafazzo JA, et al. The impact of traditional and smart pump infusion technology on nurse medication ad…
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psnet.ahrq.gov/issue/three-scans-are-better-two-follow-automatic-method-finding-missed-and-misidentified-lesions
August 17, 2022 - Study
Three scans are better than two for follow-up: an automatic method for finding missed and misidentified lesions in cross-sectional follow-up of oncology patients.
Citation Text:
Joskowicz L, Di Veroli B, Lederman R, et al. Three scans are better than two for follow-up: an automatic…
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psnet.ahrq.gov/issue/impact-errors-paper-based-and-computerized-diabetes-management-decision-support-hospitalized
April 03, 2024 - Study
Impact of errors in paper-based and computerized diabetes management with decision support for hospitalized patients with type 2 diabetes. A post-hoc analysis of a before and after study.
Citation Text:
Donsa K, Beck P, Höll B, et al. Impact of errors in paper-based and computerize…
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psnet.ahrq.gov/issue/factors-associated-use-cognitive-aids-operating-room-crises-cross-sectional-study-us
February 07, 2018 - Study
Emerging Classic
Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers.
Citation Text:
Alidina S, Goldhaber-Fiebert SN, Hannenberg A, et al. Factors associated wi…
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psnet.ahrq.gov/issue/prognosis-undiagnosed-chest-pain-linked-electronic-health-record-cohort-study
March 19, 2018 - Study
Prognosis of undiagnosed chest pain: linked electronic health record cohort study.
Citation Text:
Jordan KP, Timmis A, Croft P, et al. Prognosis of undiagnosed chest pain: linked electronic health record cohort study. BMJ. 2017;357:j1194. doi:10.1136/bmj.j1194.
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psnet.ahrq.gov/issue/readmission-rates-after-passage-hospital-readmissions-reduction-program-pre-post-analysis
October 30, 2010 - Study
Classic
Readmission rates after passage of the Hospital Readmissions Reduction Program: a pre–post analysis.
Citation Text:
Wasfy JH, Zigler CM, Choirat C, et al. Readmission Rates After Passage of the Hospital Readmissions Reduction Program: A Pre-Post An…
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www.ahrq.gov/hai/cauti-tools/impl-guide/implementation-guide-appendix-o.html
October 01, 2015 - Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Appendix O. CAUTI Event Report Template
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Table of Contents
Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Over…
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psnet.ahrq.gov/issue/high-rate-implementation-proposed-actions-improvement-healthcare-failure-mode-effect-analysis
December 09, 2020 - Study
High rate of implementation of proposed actions for improvement with the Healthcare Failure Mode Effect Analysis method: evaluation of 117 analyses.
Citation Text:
Öhrn A, Ericsson C, Andersson C, et al. High Rate of Implementation of Proposed Actions for Improvement With the Healt…
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psnet.ahrq.gov/issue/childrens-hospitals-solutions-patient-safety-collaborative-impact-hospital-acquired-harm
August 10, 2022 - Study
Classic
Children's hospitals' solutions for patient safety collaborative impact on hospital-acquired harm.
Citation Text:
Lyren A, Brilli RJ, Zieker K, et al. Children's Hospitals' Solutions for Patient Safety Collaborative Impact on Hospital-Acquired Harm…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/044-vap-prevention-essential.docx
October 01, 2024 - Ventilator-Associated Pneumonia (VAP) Prevention Essential Practices1
Avoid intubation if possible.2-3
Consider alternative strategies, such as, high flow O2 or noninvasive positive pressure ventilation.
Consider each patient’s clinical scenario to determine the most appropriate strategy.
Minimize sedation.2-5
Determ…
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psnet.ahrq.gov/issue/july-spike-fatal-medication-errors-possible-effect-new-medical-residents
February 15, 2011 - Study
Classic
A July spike in fatal medication errors: a possible effect of new medical residents.
Citation Text:
Phillips DP, Barker GEC. A July spike in fatal medication errors: a possible effect of new medical residents. J Gen Intern Med. 2010;25(8):774-9. …
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psnet.ahrq.gov/issue/polypharmacy-and-potentially-inappropriate-medication-people-dementia-nationwide-study
March 06, 2012 - Study
Emerging Classic
Polypharmacy and potentially inappropriate medication in people with dementia: a nationwide study.
Citation Text:
Kristensen RU, Nørgaard A, Jensen-Dahm C, et al. Polypharmacy and Potentially Inappropriate Medication in People with Dementi…
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psnet.ahrq.gov/issue/learning-patient-safety-incidents-green-cross-method
June 14, 2023 - Study
Learning from patient safety incidents: The Green Cross method.
Citation Text:
Jacobsen HK, Ballangrud R, Birkeli GH. Learning from patient safety incidents: the Green Cross method. Nurs Crit Care. 2024;Epub Jun 26. doi:10.1111/nicc.13114.
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DOI Go…
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www.ahrq.gov/news/newsroom/case-studies/201518.html
July 01, 2015 - New York City Uses AHRQ's TeamSTEPPS®, Other AHRQ Resources to Advance Patient Safety
Search All Impact Case Studies
July 2015
Description
New York City Health and Hospitals Corporation (HHC), the nation’s largest municipal health care delivery system, uses several AHRQ resources to improve patient care…
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psnet.ahrq.gov/issue/value-adding-verbal-report-written-handoffs-early-readmission-following-prolonged-respiratory
July 19, 2023 - Study
The value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure.
Citation Text:
Hess DR, Tokarczyk A, O'Malley M, et al. The value of adding a verbal report to written handoffs on early readmission following prolonged respira…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-p.html
May 01, 2017 - Appendix P. Evaluating and Selecting Hand Hygiene Products - Implementation Guide
Slide 1: Appendix P. Evaluating and Selecting Hand Hygiene Products
Timothy Landers, Ph.D., R.N., CNP, CIC
Assistant Professor, The Ohio State University College of Nursing
Slide 2: Disclosures
Dr. Landers receives sala…
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psnet.ahrq.gov/issue/current-teaching-and-evaluation-methods-critical-care-medicine-has-accreditation-council
February 23, 2022 - Study
Current teaching and evaluation methods in critical care medicine: has the Accreditation Council for Graduate Medical Education affected how we practice and teach in the intensive care unit?
Citation Text:
Chudgar SM, Cox CE, Que LG, et al. Current teaching and evaluation methods…
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psnet.ahrq.gov/issue/ethical-framework-allocating-scarce-life-saving-chemotherapy-and-supportive-care-drugs
September 07, 2016 - Commentary
An ethical framework for allocating scarce life-saving chemotherapy and supportive care drugs for childhood cancer.
Citation Text:
Unguru Y, Fernandez C, Bernhardt B, et al. An Ethical Framework for Allocating Scarce Life-Saving Chemotherapy and Supportive Care Drugs for Child…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/teledx-table1.html
August 01, 2020 - Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis
Table 1. Implications of Telediagnosis for Diagnostic Quality and Safety
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Table of Contents
Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis
Introduction
Ev…
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psnet.ahrq.gov/issue/clinical-and-economic-outcomes-attributable-health-care-associated-sepsis-and-pneumonia
December 09, 2015 - Study
Clinical and economic outcomes attributable to health care–associated sepsis and pneumonia.
Citation Text:
Eber MR, Laxminarayan R, Perencevich E, et al. Clinical and economic outcomes attributable to health care-associated sepsis and pneumonia. Arch Intern Med. 2010;170(4):347-53.…