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psnet.ahrq.gov/issue/trial-automated-decision-support-alerts-contraindicated-medications-using-computerized
May 20, 2019 - Study
A trial of automated decision support alerts for contraindicated medications using computerized physician order entry.
Citation Text:
Galanter W, Didomenico RJ, Polikaitis A. A trial of automated decision support alerts for contraindicated medications using computerized physician…
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psnet.ahrq.gov/issue/lessons-learned-implementing-principled-approach-resolution-following-patient-harm
February 12, 2020 - Commentary
Lessons learned from implementing a principled approach to resolution following patient harm.
Citation Text:
Smith KM, Smith LL, (Jack) Gentry JC, et al. Lessons learned from implementing a principled approach to resolution following patient harm. J Patient Saf Risk Manag. 201…
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psnet.ahrq.gov/issue/race-postoperative-complications-and-death-apparently-healthy-children
August 10, 2022 - Study
Classic
Race, postoperative complications, and death in apparently healthy children.
Citation Text:
Nafiu OO, Mpody C, Kim SS, et al. Race, postoperative complications, and death in apparently healthy children. Pediatrics. 2020;146(2):e20194113. doi:10.154…
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psnet.ahrq.gov/issue/attitudes-and-practices-related-clinical-alarms-follow-survey
June 11, 2014 - Study
Attitudes and practices related to clinical alarms: a follow-up survey.
Citation Text:
Ruppel H, Funk M, Clark T, et al. Attitudes and Practices Related to Clinical Alarms: A Follow-up Survey. Am J Crit Care. 2018;27(2):114-123. doi:10.4037/ajcc2018185.
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psnet.ahrq.gov/issue/development-medication-safety-and-quality-survey-small-rural-hospitals
July 15, 2010 - Study
Development of a medication safety and quality survey for small rural hospitals.
Citation Text:
Winterstein AG, Johns TE, Campbell KN, et al. Development of a Medication Safety and Quality Survey for Small Rural Hospitals. J Patient Saf. 2017;13(4):249-254. doi:10.1097/PTS.00000000…
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psnet.ahrq.gov/issue/online-medication-error-graphic-reports-pilot-north-carolina-nursing-homes
March 24, 2011 - Study
Online medication error graphic reports: a pilot in North Carolina nursing homes.
Citation Text:
Greene SB, Williams CE, Pierson S, et al. Online medication error graphic reports: a pilot in North Carolina nursing homes. J Patient Saf. 2011;7(2):92-8. doi:10.1097/PTS.0b013e31821b4…
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psnet.ahrq.gov/issue/comprehensive-stroke-centers-overcome-weekend-versus-weekday-gap-stroke-treatment-and
July 13, 2010 - Study
Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality.
Citation Text:
McKinney JS, Deng Y, Kasner SE, et al. Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality. Stroke. 2011;42(9)…
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psnet.ahrq.gov/issue/improving-follow-high-risk-psychiatry-outpatients-resident-year-end-transfer
January 27, 2016 - Study
Improving follow-up of high-risk psychiatry outpatients at resident year-end transfer.
Citation Text:
Young JQ, Pringle Z, Wachter R. Improving follow-up of high-risk psychiatry outpatients at resident year-end transfer. Jt Comm J Qual Patient Saf. 2011;37(7):300-308.
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psnet.ahrq.gov/issue/comparison-voluntarily-reported-medication-errors-intensive-care-and-general-care-units
October 26, 2010 - Study
A comparison of voluntarily reported medication errors in intensive care and general care units.
Citation Text:
Kane-Gill SL, Kowiatek JG, Weber RJ. A comparison of voluntarily reported medication errors in intensive care and general care units. Qual Saf Health Care. 2010;19(1):5…
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psnet.ahrq.gov/issue/error-traps-pediatric-patient-blood-management-perioperative-period
January 12, 2022 - Commentary
Error traps in pediatric patient blood management in the perioperative period.
Citation Text:
Tan GM, Murto K, Downey LA, et al. Error traps in pediatric patient blood management in the perioperative period. Paediatr Anaesth. 2023;33(8):609-619. doi:10.1111/pan.14683.
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www.ahrq.gov/news/newsroom/case-studies/201516.html
June 01, 2015 - San Diego Universities Collaborate Using TeamSTEPPS® to Boost Professional Education
Search All Impact Case Studies
June 2015
About 900 students at two San Diego universities have been instructed in the team-based methods of TeamSTEPPS® , AHRQ's evidence-based patient safety training program for health car…
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psnet.ahrq.gov/issue/transitional-chaos-or-enduring-harm-ehr-and-disruption-medicine
August 02, 2015 - Commentary
Transitional chaos or enduring harm? The EHR and the disruption of medicine.
Citation Text:
Rosenbaum L. Transitional Chaos or Enduring Harm? The EHR and the Disruption of Medicine. New Engl J Med. 2015;373(17):1585-1588. doi:10.1056/NEJMp1509961.
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psnet.ahrq.gov/issue/long-working-hours-safety-and-health-toward-national-research-agenda
November 16, 2022 - Review
Long working hours, safety, and health: toward a national research agenda.
Citation Text:
Caruso CC, Bushnell T, Eggerth D, et al. Long working hours, safety, and health: toward a National Research Agenda. Am J Ind Med. 2006;49(11):930-42.
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psnet.ahrq.gov/issue/trends-opioid-use-commercially-insured-and-medicare-advantage-populations-2007-16
March 13, 2018 - Study
Trends in opioid use in commercially insured and Medicare Advantage populations in 2007–16: retrospective cohort study.
Citation Text:
Jeffery MM, Hooten M, Henk HJ, et al. Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective coh…
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psnet.ahrq.gov/issue/impact-preoperative-briefings-operating-room-delays
July 28, 2010 - Study
Impact of preoperative briefings on operating room delays.
Citation Text:
Nundy S, Mukherjee A, Sexton B, et al. Impact of preoperative briefings on operating room delays: a preliminary report. Arch Surg. 2008;143(11):1068-72. doi:10.1001/archsurg.143.11.1068.
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psnet.ahrq.gov/issue/saving-lives-and-saving-money-hospital-acquired-conditions-update
May 01, 2017 - Government Resource
Saving Lives and Saving Money: Hospital-Acquired Conditions Update.
Citation Text:
Saving Lives and Saving Money: Hospital-Acquired Conditions Update. Rockville, MD: Agency for Healthcare Research and Quality; December 2015. AHRQ Publication No. 16-0009-EF.
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psnet.ahrq.gov/issue/communication-discrepancies-between-physicians-and-hospitalized-patients
October 12, 2022 - Study
Classic
Communication discrepancies between physicians and hospitalized patients.
Citation Text:
Olson DP, Windish DM. Communication discrepancies between physicians and hospitalized patients. Arch Intern Med. 2010;170(15):1302-1307. doi:10.1001/archintern…
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psnet.ahrq.gov/issue/tale-two-stories-contrasting-views-patient-safety
March 27, 2005 - Book/Report
Classic
A Tale of Two Stories: Contrasting Views of Patient Safety.
Citation Text:
A Tale of Two Stories: Contrasting Views of Patient Safety. Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1997.
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digital.ahrq.gov/ahrq-funded-projects/give-teens-vaccines-study/annual-summary/2012
January 01, 2012 - The Give Teens Vaccines Study - 2012
Project Name
The Give Teens Vaccines Study
Principal Investigator
Fiks, Alexander
Organization
The Children's Hospital of Philadelphia Pediatric Research Consortium
Funding Mechanism
Primary Care Practice-Based Research Network (…
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psnet.ahrq.gov/issue/computerized-prescriber-order-entry-medication-safety-cpoems-uncovering-and-learning-issues
February 05, 2014 - Book/Report
Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors.
Citation Text:
Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors. Brigham and Women's Hospital, Harvard…