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psnet.ahrq.gov/issue/evaluation-inpatient-admissions-and-potential-antimicrobial-and-analgesic-dosing-errors
September 23, 2020 - Study
Evaluation of inpatient admissions and potential antimicrobial and analgesic dosing errors in overweight children.
Citation Text:
Miller JL, Johnson PN, Harrison DL, et al. Evaluation of inpatient admissions and potential antimicrobial and analgesic dosing errors in overweight chi…
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psnet.ahrq.gov/issue/impact-adverse-events-prescribing-warfarin-patients-atrial-fibrillation-matched-pair-analysis
August 15, 2018 - Study
Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis.
Citation Text:
Choudhry NK, Anderson G, Laupacis A, et al. Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis. B…
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psnet.ahrq.gov/issue/effects-technological-interventions-safety-medication-use-system
May 11, 2016 - Study
Effects of technological interventions on the safety of a medication-use system.
Citation Text:
Skibinski K, White BA, Lin LI-K, et al. Effects of technological interventions on the safety of a medication-use system. Am J Health Syst Pharm. 2007;64(1):90-6.
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www.ahrq.gov/news/newsroom/case-studies/202402.html
July 01, 2024 - Sierra Vista Hospital Uses AHRQ Toolkit To Slash Catheter Use and Eliminate Infections
Search All Impact Case Studies
July 2024
Sierra Vista Hospital, an 11-bed critical access hospital in Truth or Consequences, New Mexico, implemented practices from AHRQ’s Toolkit for Reducing Catheter-Associated Urinary …
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psnet.ahrq.gov/issue/medication-errors-family-practice-hospitals-and-after-discharge-hospital-ethical-analysis
September 23, 2020 - Commentary
Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.
Citation Text:
Clark PA. Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis. J Law Med Ethics. 2004;32(2)…
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psnet.ahrq.gov/issue/more-tick-box-medical-checklist-development-design-and-use
December 02, 2020 - Commentary
More than a tick box: medical checklist development, design, and use.
Citation Text:
Burian BK, Clebone A, Dismukes K, et al. More Than a Tick Box: Medical Checklist Development, Design, and Use. Anesth Analg. 2018;126(1):223-232. doi:10.1213/ANE.0000000000002286.
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psnet.ahrq.gov/issue/effect-pharmacist-adverse-drug-events-and-medication-errors-outpatients-cardiovascular
July 31, 2013 - Study
Effect of a pharmacist on adverse drug events and medication errors in outpatients with cardiovascular disease.
Citation Text:
Murray MD, Ritchey ME, Wu J, et al. Effect of a pharmacist on adverse drug events and medication errors in outpatients with cardiovascular disease. Arch …
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psnet.ahrq.gov/issue/alarm-fatigue-impacts-patient-safety
December 02, 2020 - Review
Alarm fatigue: impacts on patient safety.
Citation Text:
Ruskin KJ, Hueske-Kraus D. Alarm fatigue: impacts on patient safety. Curr Opin Anaesthesiol. 2015;28(6):685-690. doi:10.1097/ACO.0000000000000260.
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psnet.ahrq.gov/issue/framework-direct-observation-performance-and-safety-healthcare
November 15, 2023 - Commentary
Framework for direct observation of performance and safety in healthcare.
Citation Text:
Catchpole K, Neyens DM, Abernathy J, et al. Framework for direct observation of performance and safety in healthcare. BMJ Qual Saf. 2017;26(12):1015-1021. doi:10.1136/bmjqs-2016-006407.
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psnet.ahrq.gov/issue/surgeon-reported-conflict-intensivists-about-postoperative-goals-care
September 26, 2012 - Study
Surgeon-reported conflict with intensivists about postoperative goals of care.
Citation Text:
Olson TJP, Brasel KJ, Redmann AJ, et al. Surgeon-reported conflict with intensivists about postoperative goals of care. JAMA Surg. 2013;148(1):29-35. doi:10.1001/jamasurgery.2013.403.
Co…
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hcup-us.ahrq.gov/news/exhibit_booth/NEDSBrochure_050218.pdf
May 16, 2018 - What is the NEDS?
The Nationwide Emergency Department Sample
(NEDS) is part of the family of databases and
software tools developed for the Healthcare Cost
and Utilization Project (HCUP). The NEDS
produces national estimates about emergency
department visits across the country. The NEDS
describes emergency department v…
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psnet.ahrq.gov/issue/managing-unnecessary-variability-patient-demand-reduce-nursing-stress-and-improve-patient
August 04, 2021 - Study
Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety.
Citation Text:
Litvak E, Buerhaus P, Davidoff F, et al. Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety. Jt Comm J Qual Pat…
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psnet.ahrq.gov/issue/promoting-patient-safety-results-teamstepps-initiative
October 17, 2012 - Commentary
Promoting patient safety: results of a TeamSTEPPS initiative.
Citation Text:
Gaston T, Short N, Ralyea C, et al. Promoting patient safety: results of a TeamSTEPPS initiative. J Nurs Adm. 2016;46(4):201-207. doi:10.1097/nna.0000000000000333.
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psnet.ahrq.gov/issue/anticoagulation-patient-safety-goal-compliance-university-health-system-methods-achieving
March 09, 2022 - Commentary
Anticoagulation patient safety goal compliance at a university health system: methods for achieving the goal.
Citation Text:
Franco AC, Maxwell P, Green K, et al. Anticoagulation Patient Safety Goal Compliance at a University Health System: Methods for Achieving the Goal. Hosp…
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psnet.ahrq.gov/issue/pediatric-quality-and-safety-nursing-perspective
February 15, 2017 - Review
Pediatric quality and safety: a nursing perspective.
Citation Text:
Butler GA, Hupp DS. Pediatric Quality and Safety. Pediatr Clin North Am. 2016;63(2). doi:10.1016/j.pcl.2015.11.005.
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psnet.ahrq.gov/issue/interventions-reducing-medication-errors-children-hospital
May 19, 2018 - Review
Interventions for reducing medication errors in children in hospital.
Citation Text:
Maaskant JM, Vermeulen H, Apampa B, et al. Interventions for reducing medication errors in children in hospital. Cochrane Database Syst Rev. 2015;(3):CD006208. doi:10.1002/14651858.CD006208.pub3. …
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psnet.ahrq.gov/issue/teamwork-and-error-operating-room-analysis-skills-and-roles
April 15, 2009 - Study
Teamwork and error in the operating room: analysis of skills and roles.
Citation Text:
Catchpole K, Mishra A, Handa A, et al. Teamwork and error in the operating room: analysis of skills and roles. Ann Surg. 2008;247(4):699-706. doi:10.1097/SLA.0b013e3181642ec8.
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psnet.ahrq.gov/issue/assessing-diagnostic-reasoning-consensus-statement-summarizing-theory-practice-and-future
August 11, 2015 - Commentary
Assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs.
Citation Text:
Ilgen JS, Humbert AJ, Kuhn G, et al. Assessing diagnostic reasoning: a consensus statement summarizing theory, practice, and future needs. Acad Emerg Med. 20…
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psnet.ahrq.gov/issue/automatic-errors-case-series-errors-inherent-electronic-prescribing
March 14, 2022 - Commentary
Automatic errors: a case series on the errors inherent in electronic prescribing.
Citation Text:
Lourenco LM, Bursua A, Groo VL. Automatic Errors: A Case Series on the Errors Inherent in Electronic Prescribing. J Gen Intern Med. 2016;31(7):808-811. doi:10.1007/s11606-016-3606-…
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psnet.ahrq.gov/issue/it-time-safeguards-adoption-robotic-surgery
December 04, 2019 - Commentary
Is it time for safeguards in the adoption of robotic surgery?
Citation Text:
Sheetz KH, Dimick JB. Is It Time for Safeguards in the Adoption of Robotic Surgery? JAMA. 2019;321(20):1971-1972. doi:10.1001/jama.2019.3736.
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