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psnet.ahrq.gov/issue/dropping-baton-during-handoff-emergency-department-primary-care-pediatric-asthma-continuity
March 14, 2022 - Study
Dropping the baton during the handoff from emergency department to primary care: pediatric asthma continuity errors.
Citation Text:
Hsiao AL, Shiffman RN. Dropping the baton during the handoff from emergency department to primary care: pediatric asthma continuity errors. Jt Comm J …
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psnet.ahrq.gov/issue/impact-rapid-response-system-implementation-critical-deterioration-events-children
November 06, 2015 - Study
Impact of rapid response system implementation on critical deterioration events in children.
Citation Text:
Bonafide CP, Localio R, Roberts KE, et al. Impact of rapid response system implementation on critical deterioration events in children. JAMA Pediatr. 2014;168(1):25-33. doi:1…
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psnet.ahrq.gov/issue/accreditation-council-graduate-medical-educations-limits-residents-work-hours-and-patient
July 10, 2008 - Study
Classic
The Accreditation Council for Graduate Medical Education's limits on residents' work hours and patient safety.
Citation Text:
Jagsi R, Weinstein DF, Shapiro J, et al. The Accreditation Council for Graduate Medical Education's limits on residents'…
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psnet.ahrq.gov/issue/residents-response-duty-hour-regulations-follow-national-survey
December 02, 2014 - Study
Classic
Residents' response to duty-hour regulations—a follow-up national survey.
Citation Text:
Drolet BC, Christopher DA, Fischer SA. Residents' response to duty-hour regulations--a follow-up national survey. N Engl J Med. 2012;366(24):e35. doi:10.1056…
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psnet.ahrq.gov/issue/monitoring-harm-associated-use-anticoagulants-pediatric-populations-through-trigger-based
November 11, 2015 - Study
Monitoring the harm associated with use of anticoagulants in pediatric populations through trigger-based automated adverse-event detection.
Citation Text:
Patregnani JT, Spaeder MC, Lemon V, et al. Monitoring the harm associated with use of anticoagulants in pediatric populations t…
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psnet.ahrq.gov/issue/out-hospital-medication-errors-among-young-children-united-states-2002-2012
June 14, 2017 - Study
Out-of-hospital medication errors among young children in the United States, 2002–2012.
Citation Text:
Smith MD, Spiller HA, Casavant MJ, et al. Out-of-hospital medication errors among young children in the United States, 2002-2012. Pediatrics. 2014;134(5):867-76. doi:10.1542/peds.…
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psnet.ahrq.gov/issue/developing-and-evaluating-automated-all-cause-harm-trigger-system
July 31, 2013 - Study
Developing and evaluating an automated all-cause harm trigger system.
Citation Text:
Sammer C, Miller S, Jones C, et al. Developing and Evaluating an Automated All-Cause Harm Trigger System. Jt Comm J Qual Patient Saf. 2017;43(4):155-165. doi:10.1016/j.jcjq.2017.01.004.
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psnet.ahrq.gov/issue/weekend-effect-pediatric-surgery-increased-mortality-children-undergoing-urgent-surgery
February 01, 2012 - Study
Classic
The "weekend effect" in pediatric surgery—increased mortality for children undergoing urgent surgery during the weekend.
Citation Text:
Goldstein SD, Papandria DJ, Aboagye J, et al. The "weekend effect" in pediatric surgery - increased mortality fo…
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psnet.ahrq.gov/issue/accuracy-pediatric-trauma-field-triage-systematic-review
November 04, 2020 - Review
Accuracy of pediatric trauma field triage: a systematic review.
Citation Text:
van der Sluijs R, van Rein EAJ, Wijnand JGJ, et al. Accuracy of Pediatric Trauma Field Triage: A Systematic Review. JAMA Surg. 2018;153(7):671-676. doi:10.1001/jamasurg.2018.1050.
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psnet.ahrq.gov/issue/hospital-leadership-and-quality-improvement-rhetoric-versus-reality
May 07, 2014 - Study
Hospital leadership and quality improvement: rhetoric versus reality.
Citation Text:
Levey S, Vaughn T, Koepke M, et al. Hospital Leadership and Quality Improvement. J Patient Saf. 2008;3(1). doi:10.1097/pts.0b013e3180311256.
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DOI Google Scholar…
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psnet.ahrq.gov/issue/disclosure-hospital-adverse-events-and-its-association-patients-ratings-quality-care
December 29, 2014 - Study
Disclosure of hospital adverse events and its association with patients' ratings of the quality of care.
Citation Text:
López L, Weissman JS, Schneider EC, et al. Disclosure of hospital adverse events and its association with patients' ratings of the quality of care. Arch Intern Me…
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psnet.ahrq.gov/issue/evaluating-serial-strategies-preventing-wrong-patient-orders-nicu
November 03, 2015 - Study
Evaluating serial strategies for preventing wrong-patient orders in the NICU.
Citation Text:
Adelman JS, Aschner JL, Schechter CB, et al. Evaluating Serial Strategies for Preventing Wrong-Patient Orders in the NICU. Pediatrics. 2017;139(5). doi:10.1542/peds.2016-2863.
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psnet.ahrq.gov/issue/analysis-adverse-events-associated-adult-moderate-procedural-sedation-outside-operating-room
August 13, 2014 - Study
Analysis of adverse events associated with adult moderate procedural sedation outside the operating room.
Citation Text:
Karamnov S, Sarkisian N, Grammer R, et al. Analysis of Adverse Events Associated With Adult Moderate Procedural Sedation Outside the Operating Room. J Patient Sa…
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psnet.ahrq.gov/issue/registration-errors-among-patients-receiving-blood-transfusions-national-analysis-2008-2017
March 18, 2020 - Study
Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017.
Citation Text:
Vijenthira S, Armali C, Downie H, et al. Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017. Vox Sang. 2021;116…
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www.ahrq.gov/nhguide/toolkits/determine-whether-to-treat/toolkit2-communications-and-decisionmaking.html
November 01, 2016 - Toolkit 2. Common Suspected Infections: Communication and Decisionmaking for Four Infections
Toolkit Effectiveness
When tested in six nursing homes in an intervention group and six in a comparison group, this toolkit demonstrated a small reduction in prescribing in the intervention group relative to the compa…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-practice-assessments.pdf
June 02, 2025 - Job Aid: Practice Assessments and Surveys
Primary Care Practice Facilitator
Training Series
1
Job Aid: Practice Assessments and Surveys
Overview
Practice assessments and surveys are simple and non-threatening ways for a practice to gather
information, generate ideas for improvements, and test and…
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psnet.ahrq.gov/issue/morning-handover-call-issues-opportunities-improvement
September 26, 2012 - Study
Morning handover of on-call issues: opportunities for improvement.
Citation Text:
Devlin MK, Kozij NK, Kiss A, et al. Morning handover of on-call issues: opportunities for improvement. JAMA Intern Med. 2014;174(9):1479-85. doi:10.1001/jamainternmed.2014.3033.
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psnet.ahrq.gov/issue/unscheduled-returns-emergency-department-outcome-medical-errors
November 12, 2014 - Study
Unscheduled returns to the emergency department: an outcome of medical errors?
Citation Text:
Nuñez S, Hexdall A, Aguirre-Jaime A. Unscheduled returns to the emergency department: an outcome of medical errors? Qual Saf Health Care. 2006;15(2):102-8.
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www.ahrq.gov/takeheart/training/implementing-automatic-referral/index.html
April 01, 2023 - Implementing Automatic Referral
This focus area will walk you through the necessary steps for implementing an automatic referral system in your hospital.
Automatic referral is a proven, evidence-based strategy to increase participation in cardiac rehabilitation (CR). Automatic referral is the systematic, au…
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psnet.ahrq.gov/issue/reporting-sentinel-events-swedish-hospitals-comparison-severe-adverse-events-reported
December 09, 2020 - Study
Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by patients and providers.
Citation Text:
Öhrn A, Elfström J, Liedgren C, et al. Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by …