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psnet.ahrq.gov/node/853959/psn-pdf
September 27, 2023 - Scaling up a diagnostic pause at the ICU-to-ward
transition: an exploration of barriers and facilitators to
implementation of the ICU-PAUSE handoff tool.
September 27, 2023
Cornell EG, Harris E, McCune E, et al. Scaling up a diagnostic pause at the ICU-to-ward transition: an
exploration of barriers and facilitator…
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psnet.ahrq.gov/node/847046/psn-pdf
April 05, 2023 - Indication documentation and indication-based
prescribing within electronic prescribing systems: a
systematic review and narrative synthesis.
April 5, 2023
Feather C, Appelbaum N, Darzi A, et al. Indication documentation and indication-based prescribing within
electronic prescribing systems: a systematic review an…
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psnet.ahrq.gov/node/41211/psn-pdf
January 03, 2017 - He thought the "lady in the door" was the "lady in the
window": a qualitative study of patient identification
practices.
January 3, 2017
Phipps E, Turkel M, Mackenzie ER, et al. He thought the "lady in the door" was the "lady in the window": a
qualitative study of patient identification practices. Jt Comm J Qual P…
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psnet.ahrq.gov/node/47606/psn-pdf
January 30, 2019 - Importance of safety climate, teamwork climate and
demographics: understanding nurses, allied health
professionals and clerical staff perceptions of patient
safety.
January 30, 2019
Zaheer S, Ginsburg LR, Wong HJ, et al. Importance of safety climate, teamwork climate and
demographics: understanding nurses, allied…
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psnet.ahrq.gov/node/74154/psn-pdf
December 08, 2021 - Assessment of requests for medication-related follow-up
after hospital discharge, and the relation to unplanned
hospital revisits, in older patients: a multicentre
retrospective chart review.
December 8, 2021
Cam H, Kempen TGH, Eriksson H, et al. Assessment of requests for medication-related follow-up after
hospi…
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psnet.ahrq.gov/node/846161/psn-pdf
March 15, 2023 - Ten years of online incident reporting and learning using
CPiRLS: implications for improved patient safety.
March 15, 2023
Thomas M, Swait G, Finch R. Ten years of online incident reporting and learning using CPiRLS:
implications for improved patient safety. Chiropr Man Therap. 2023;31(1):9. doi:10.1186/s12998-023-…
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psnet.ahrq.gov/node/844758/psn-pdf
September 18, 2019 - The fifth vital sign? Nurse worry predicts inpatient
deterioration within 24 hours.
September 18, 2019
Romero-Brufau S, Gaines K, Nicolas CT, et al. JAMIA Open. 2019;2(4):465-470.
https://psnet.ahrq.gov/issue/fifth-vital-sign-nurse-worry-predicts-inpatient-deterioration-within-24-hours
Early recognition of clinica…
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psnet.ahrq.gov/node/34732/psn-pdf
May 09, 2015 - A Tale of Two Stories: Contrasting Views of Patient
Safety.
May 9, 2015
Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1997.
https://psnet.ahrq.gov/issue/tale-two-stories-contrasting-views-patient-safety
A report from a workshop, this document is a well-written look at the difference…
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psnet.ahrq.gov/node/45479/psn-pdf
October 08, 2016 - Physician understanding and ability to communicate
harms and benefits of common medical treatments.
October 8, 2016
Krouss M, Croft LD, Morgan DJ. Physician Understanding and Ability to Communicate Harms and Benefits
of Common Medical Treatments. JAMA Intern Med. 2016;176(10):1565-1567.
doi:10.1001/jamainternmed.2…
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psnet.ahrq.gov/node/73288/psn-pdf
May 19, 2021 - 2020 Pennsylvania Patient Safety Reporting: an analysis
of serious events and incidents from the nation’s largest
event reporting database.
May 19, 2021
Kepner S, Jones RM. 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and
incidents from the nation’s largest event reporting database. Pa…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/operation-sequence-diagram
January 01, 2023 - Operation Sequence Diagram
Acronym
OSD
Description
Operation sequence diagrams (OSD) are graphical representations of team interaction in a network. They portray how tasks are performed and how individuals interact over time.
Uses
To portray graphically how teams interact in a networ…
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www.ahrq.gov/evidencenow/projects/urinary/resources/improvement-budget-recruitment.html
April 01, 2018 - Back to MUI Resources
Engaging Primary Care Practices in Studies of Improvement: Did You Budget Enough for Practice Recruitment?
Resource
Full Article on PubMed.
Summary
There is increased interest nationally in multicenter clinical trials to answer questions about clinical e…
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www.ahrq.gov/cpi/about/organization/nac/hernandez-cancio.html
February 01, 2025 - NAC Member Biography: Sinsi Hernández-Cancio
Sinsi Hernández-Cancio, J.D. Vice President for Health Justice National Partnership for Women & Families Sinsi Hernández-Cancio, J.D. , is vice president for health justice, at the National Partnership for Women & Families. She is a national health and healthcare…
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www.uspreventiveservicestaskforce.org/uspstf/update-on-methods-insufficient-evidence---table-3
February 01, 2009 - Update on Methods: Insufficient Evidence - Table 3
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Table 3. Application of the 4 Domains: Skin Cancer Screening Using Visual Inspection
Domain
Information
Pot…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/GLeN36Z8CZQyCFHmYVnABE
Screening for Oral Cancer: Clinical Summary of USPSTF Recommendation
SCREENING FOR ORAL CANCER
CLINICAL SUMMARY OF U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATION
Population Asymptomatic adults aged 18 years or older
Recommendation
No recommendation.
Grade: I statement
Risk Assessment
The…
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psnet.ahrq.gov/node/853620/psn-pdf
September 20, 2023 - Impact of pharmacist-led admission medication
reconciliation on patient outcomes in a large health
system.
September 20, 2023
Kramer JS, Hayley Burgess L, Warren C, et al. Impact of pharmacist-led admission medication
reconciliation on patient outcomes in a large health system. J Patient Saf Risk Manag. 2023;28(6)…
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psnet.ahrq.gov/node/73242/psn-pdf
May 12, 2021 - Strategies to prevent missed nursing care: an
international qualitative study based upon a positive
deviance approach.
May 12, 2021
Longhini J, Papastavrou E, Efstathiou G, et al. Strategies to prevent missed nursing care: an international
qualitative study based upon a positive deviance approach. J Nurs Manag. 20…
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psnet.ahrq.gov/node/39233/psn-pdf
August 02, 2013 - Rapid response teams: a systematic review and meta-
analysis.
August 2, 2013
Chan PS, Jain R, Nallmothu BK, et al. Rapid Response Teams: A Systematic Review and Meta-analysis.
Arch Intern Med. 2010;170(1):18-26. doi:10.1001/archinternmed.2009.424.
https://psnet.ahrq.gov/issue/rapid-response-teams-systematic-review…
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psnet.ahrq.gov/node/37562/psn-pdf
June 14, 2011 - Effectiveness and efficiency of root cause analysis in
medicine.
June 14, 2011
Wu AW. Effectiveness and Efficiency of Root Cause Analysis in Medicine. JAMA. 2008;299(6):685-687.
doi:10.1001/jama.299.6.685.
https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine
Application of root c…
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psnet.ahrq.gov/node/38758/psn-pdf
July 08, 2009 - An international review of patient safety measures in
radiotherapy practice.
July 8, 2009
Shafiq J, Barton M, Noble DJ, et al. An international review of patient safety measures in radiotherapy
practice. Radiother Oncol. 2009;92(1):15-21. doi:10.1016/j.radonc.2009.03.007.
https://psnet.ahrq.gov/issue/international…