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psnet.ahrq.gov/issue/effect-lean-quality-improvement-implementation-program-surgical-pathology-specimen
December 03, 2014 - Study
The effect of a Lean quality improvement implementation program on surgical pathology specimen accessioning and gross preparation error frequency.
Citation Text:
Smith ML, Wilkerson T, Grzybicki DM, et al. The effect of a Lean quality improvement implementation program on surgical …
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psnet.ahrq.gov/issue/development-and-implementation-subcutaneous-insulin-pen-label-bar-code-scanning-protocol
October 19, 2022 - Study
Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors.
Citation Text:
MacMaster HW, Gonzalez S, Maruoka A, et al. Development and Implementation of a Subcutaneous Insulin Pen Label Bar Code Scanning…
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psnet.ahrq.gov/issue/diagnostic-errors-primary-care-pediatrics-project-redde
April 08, 2018 - Study
Diagnostic errors in primary care pediatrics: Project RedDE.
Citation Text:
Rinke ML, Singh H, Heo M, et al. Diagnostic Errors in Primary Care Pediatrics: Project RedDE. Acad Peds. 2018;18(2):220-227. doi:10.1016/j.acap.2017.08.005.
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psnet.ahrq.gov/issue/measuring-team-hierarchy-during-high-stakes-clinical-decision-making-development-and
April 05, 2023 - Study
Measuring team hierarchy during high-stakes clinical decision making: development and validation of a new behavioral observation method.
Citation Text:
Johansson AC, Manago B, Sell J, et al. Measuring team hierarchy during high-stakes clinical decision making: development and valid…
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psnet.ahrq.gov/issue/parent-experiences-process-sharing-inpatient-safety-concerns-children-medical-complexity
July 06, 2022 - Study
Parent experiences with the process of sharing inpatient safety concerns for children with medical complexity: a qualitative analysis.
Citation Text:
Kieren MQ, Kelly MM, Garcia MA, et al. Parent experiences with the process of sharing inpatient safety concerns for children with me…
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psnet.ahrq.gov/issue/randomized-controlled-trial-pictogram-based-intervention-reduce-liquid-medication-dosing
June 04, 2014 - Study
Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children.
Citation Text:
Yin S, Dreyer BP, van Schaick L, et al. Randomized controlled trial of a pictogram-based intervention …
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psnet.ahrq.gov/issue/effect-hospital-follow-appointment-clinical-event-outcomes-and-mortality
April 24, 2018 - Study
Effect of hospital follow-up appointment on clinical event outcomes and mortality.
Citation Text:
Grafft CA, McDonald FS, Ruud KL, et al. Effect of hospital follow-up appointment on clinical event outcomes and mortality. Arch Intern Med. 2010;170(11):955-60. doi:10.1001/archinternm…
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www.ahrq.gov/news/newsroom/case-studies/201520.html
July 01, 2015 - Wisconsin Critical Access Hospital Sees Big Results with AHRQ’s CUSP, RED and TeamSTEPPS®
Search All Impact Case Studies
July 2015
Amery Hospital & Clinic, a 25-bed acute care critical access hospital in rural Wisconsin, used AHRQ’s Comprehensive Unit-based Safety Program (CUSP) to reduce surgical site in…
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psnet.ahrq.gov/issue/sbar-improves-nurse-physician-communication-and-reduces-unexpected-death-pre-and-post
November 21, 2018 - Study
SBAR improves nurse–physician communication and reduces unexpected death: a pre and post intervention study.
Citation Text:
De Meester K, Verspuy M, Monsieurs KG, et al. SBAR improves nurse-physician communication and reduces unexpected death: a pre and post intervention study. Re…
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psnet.ahrq.gov/issue/are-language-barriers-associated-serious-medical-events-hospitalized-pediatric-patients
November 16, 2022 - Study
Classic
Are language barriers associated with serious medical events in hospitalized pediatric patients?
Citation Text:
Cohen AL. Are Language Barriers Associated With Serious Medical Events in Hospitalized Pediatric Patients? Pediatrics. 2005;116(3):575…
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psnet.ahrq.gov/issue/effect-emergency-department-boarding-order-completion
January 29, 2018 - Study
The effect of emergency department boarding on order completion.
Citation Text:
Coil CJ, Flood JD, Belyeu BM, et al. The Effect of Emergency Department Boarding on Order Completion. Ann Emerg Med. 2016;67(6):730-736.e2. doi:10.1016/j.annemergmed.2015.09.018.
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psnet.ahrq.gov/issue/efficiency-and-safety-speech-recognition-documentation-electronic-health-record
February 14, 2024 - Study
Efficiency and safety of speech recognition for documentation in the electronic health record.
Citation Text:
Hodgson T, Magrabi F, Coiera E. Efficiency and safety of speech recognition for documentation in the electronic health record. J Am Med Inform Assoc. 2017;24(6):1127-1133. …
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psnet.ahrq.gov/issue/post-implementation-optimization-medication-alerts-hospital-computerized-provider-order-entry
December 31, 2014 - Review
Post-implementation optimization of medication alerts in hospital computerized provider order entry systems: a scoping review.
Citation Text:
Ledger TS, Brooke-Cowden K, Coiera E. Post-implementation optimization of medication alerts in hospital computerized provider order entry s…
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psnet.ahrq.gov/issue/ambulance-diversion-associated-reduced-access-cardiac-technology-and-increased-one-year
October 27, 2016 - Study
Ambulance diversion associated with reduced access to cardiac technology and increased one-year mortality.
Citation Text:
Shen Y-C, Hsia RY. Ambulance diversion associated with reduced access to cardiac technology and increased one-year mortality. Health Aff (Millwood). 2015;34(8):…
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psnet.ahrq.gov/issue/reduce-likelihood-patient-harm-associated-use-anticoagulant-therapy-commentary
November 07, 2018 - Commentary
Reduce the likelihood of patient harm associated with the use of anticoagulant therapy: commentary from the Anticoagulation Forum on the Updated Joint Commission NPSG.03.05.01 Elements of Performance
Citation Text:
Dager WE, Ansell J, Barnes GD, et al. “Reduce the Likelihood o…
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psnet.ahrq.gov/issue/implementation-online-reporting-system-identify-unprofessional-behaviors-and-mistreatment
July 13, 2022 - Study
Implementation of an online reporting system to identify unprofessional behaviors and mistreatment directed at trainees at an academic medical center.
Citation Text:
Leitman IM, Muller D, Miller S, et al. Implementation of an online reporting system to identify unprofessional behav…
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psnet.ahrq.gov/issue/comparative-review-patient-safety-initiatives-national-health-information-technology
November 03, 2015 - Review
A comparative review of patient safety initiatives for national health information technology.
Citation Text:
Magrabi F, Aarts J, Nohr C, et al. A comparative review of patient safety initiatives for national health information technology. Int J Med Inform. 2013;82(5):e139-48. d…
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psnet.ahrq.gov/issue/persistent-next-day-effects-excessive-alcohol-consumption-laparoscopic-surgical-performance
August 25, 2011 - Study
Persistent next-day effects of excessive alcohol consumption on laparoscopic surgical performance.
Citation Text:
Gallagher AG, Boyle E, Toner P, et al. Persistent next-day effects of excessive alcohol consumption on laparoscopic surgical performance. Arch Surg. 2011;146(4):419-26.…
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psnet.ahrq.gov/issue/medical-liability-climate-and-prospects-reform
September 29, 2017 - Commentary
The medical liability climate and prospects for reform.
Citation Text:
Mello MM, Studdert DM, Kachalia A. The medical liability climate and prospects for reform. JAMA. 2014;312(20):2146-55. doi:10.1001/jama.2014.10705.
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cds.ahrq.gov/sites/default/files/cds/artifact/136331/Benzodiazepine%20Patient%20Handout.pdf
January 01, 2018 - Microsoft PowerPoint - Updated Handouts - Read-Only
REDUCING MEDICATIONS SAFELY
TO MEET LIFE’S CHANGES … taking:_____________________
Your dose: _____________________________________________
WHY CONSIDER REDUCING … Adapted from “Reducing Medications Safely to Meet Life’s Changes, Focus on Benzodiazepine Receptor Agonists