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psnet.ahrq.gov/issue/disclosing-errors-affect-multiple-patients
April 19, 2017 - Commentary
Disclosing errors that affect multiple patients.
Citation Text:
Chafe R, Levinson W, Sullivan T. Disclosing errors that affect multiple patients. CMAJ. 2009;180(11):1125-7. doi:10.1503/cmaj.081016.
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psnet.ahrq.gov/issue/assessing-performance-aging-surgeons
September 07, 2016 - Commentary
Assessing the performance of aging surgeons.
Citation Text:
Katlic MR, Coleman JA, Russell MM. Assessing the Performance of Aging Surgeons. JAMA. 2019;321(5):449-450. doi:10.1001/jama.2018.22216.
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psnet.ahrq.gov/issue/patient-safety-honoring-advanced-directives
June 23, 2009 - Commentary
Patient safety: honoring advanced directives.
Citation Text:
Tice MA. Patient safety: honoring advanced directives. Home Healthc Nurse. 2007;25(2):79-81.
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psnet.ahrq.gov/issue/risk-mistaken-dnr-orders
October 19, 2022 - Study
Risk of mistaken DNR orders.
Citation Text:
Rohrer JE, Esler WV, Saeed Q, et al. Risk of mistaken DNR orders. Supportive Care in Cancer. 2006;14(8). doi:10.1007/s00520-006-0023-z.
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psnet.ahrq.gov/issue/applying-toyota-production-system-using-patient-safety-alert-system-reduce-error
June 21, 2015 - Commentary
Applying the Toyota Production System: using a patient safety alert system to reduce error.
Citation Text:
Furman C, Caplan RA. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007;33(7):376-386.
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psnet.ahrq.gov/issue/mcneil-consumer-specialty-pharmaceuticals-announces-nationwide-recall-childrens-tylenol
August 19, 2020 - Press Release/Announcement
McNeil Consumer & Specialty Pharmaceuticals announces nationwide recall of Children's Tylenol Meltaways - 80 Mg, Children's Tylenol Softchews - 80 Mg and Jr. Tylenol Meltaways - 160 Mg [press release].
Citation Text:
McNeil Consumer & Specialty Pharmaceuticals…
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psnet.ahrq.gov/issue/effects-sleep-inertia-cognition
April 21, 2021 - Study
Effects of sleep inertia on cognition.
Citation Text:
Wertz AT, Ronda JM, Czeisler CA, et al. Effects of sleep inertia on cognition. JAMA. 2006;295(2):163-4.
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psnet.ahrq.gov/issue/hospital-mortality-when-failure-not-good-measure-success
December 22, 2010 - Commentary
Hospital mortality: when failure is not a good measure of success.
Citation Text:
Shojania KG, Forster AJ. Hospital mortality: when failure is not a good measure of success. CMAJ. 2008;179(2):153-7. doi:10.1503/cmaj.080010.
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psnet.ahrq.gov/issue/start-year-right-preventing-these-top-10-medication-errors-and-hazards-2020
February 09, 2022 - Newspaper/Magazine Article
Start the year off right by preventing these top 10 medication errors and hazards from 2020.
Citation Text:
Start the year off right by preventing these top 10 medication errors and hazards from 2020. ISMP Medication Safety Alert! Acute care edition. January 27…
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psnet.ahrq.gov/issue/students-have-key-role-culture-safety-analysis-student-associated-medication-incidents
July 25, 2018 - Newspaper/Magazine Article
Students have a key role in a culture of safety: analysis of student-associated medication incidents.
Citation Text:
Students have a key role in a culture of safety: analysis of student-associated medication incidents. ISMP Medication Safety Alert! Acute care e…
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psnet.ahrq.gov/issue/radically-redesigning-patient-safety
November 13, 2024 - Newspaper/Magazine Article
Radically redesigning patient safety.
Citation Text:
Radick LE. Radically Redesigning Patient Safety. Healthcare executive. 2016;31(2):32-4, 36-40, 42.
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psnet.ahrq.gov/issue/patient-perceptions-missed-nursing-care
September 27, 2017 - Study
Patient perceptions of missed nursing care.
Citation Text:
Kalisch BJ, McLaughlin M, Dabney BW. Patient perceptions of missed nursing care. Jt Comm J Qual Patient Saf. 2012;38(4):161-7.
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digital.ahrq.gov/sites/default/files/docs/publication/Hoonakkeretal_WWCS2007.pdf
June 16, 2021 - Microsoft Word - Hoonakker et al WWCS 2007.doc
Proposed theme: 3.2 or 1.4 Prefer to have it as a poster: No
Measuring end user satisfaction in CPOE implementation
Peter Hoonakker & Pascale Carayon
E: phoonakker@cqpi.engr.wisc.edu
Center for Quality and Productivity Improvement, University of Wis…
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psnet.ahrq.gov/issue/new-mother-number-14
August 18, 2021 - Commentary
New mother number 14.
Citation Text:
New mother number 14. Sangarlangkarn A. Healthc (Amst). 2019;7:31-32.
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www.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy4/index.html
December 01, 2017 - Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning
Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality. To promote stronger engagement, Agency for Healthcare Research and Quality developed the Guide to Patient…
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www.ahrq.gov/teamstepps-program/curriculum/communication/overview/index.html
June 01, 2023 - Section 1: Overview of Key Concepts and Tools
This section provides an overview of the key concepts and tools in the Communication Module. More explanations and illustrations are provided in section 2 of this module ; methods for teaching the concepts and tools for this module are in section 3 . Information a…
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK1_T1-SBAR_UTI_Final.pdf
June 01, 2014 - Advancing Excellence in Health Care www.ahrq.gov
Agency for Healthcare Research and Quality
HAIs
Healthcare-
Associated
Infections
PREVENT
Advancing Excellence in Health Care www.ahrq.gov
Agency for Healthcare Research and Quality
HAIs
Healthcare-
Associated
Infections
PREVENT
Date/Time _________________…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/material-guide.html
June 01, 2017 - Material Use Guide - Sustainability Module
Overview
Definition of Sustainability and its Importance in Quality Improvement
Slides 4-8
Linking Sustainability and Spread
Slides 9-10
Planning Early for Sustainability
Slides 11-12
Barriers and Solutions to Sustain…
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psnet.ahrq.gov/issue/enhanced-time-out-improved-communication-process
October 19, 2022 - Commentary
Enhanced time out: an improved communication process.
Citation Text:
Nelson PE. Enhanced Time Out: An Improved Communication Process. AORN J. 2017;105(6):564-570. doi:10.1016/j.aorn.2017.03.014.
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/tool.html
June 01, 2017 - Sustainability Tool - Sustainability Module
Background: This tool can be used to identify sustainability issues in planning and implementing your improvement efforts.
How to use this tool: The Implementation Team leader (or individual designated by the leader) should complete this checklist.
Us…