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psnet.ahrq.gov/issue/improving-transitions-care-patients-warfarin-safe-transitions-anticoagulation-report
April 22, 2011 - Study
Improving transitions of care for patients on warfarin: the Safe Transitions Anticoagulation Report.
Citation Text:
Dunn AS, Shetreat-Klein A, Berman J, et al. Improving transitions of care for patients on warfarin: The safe transitions anticoagulation report. J Hosp Med. 2015;10(9…
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psnet.ahrq.gov/issue/acute-hepatitis-c-virus-infections-attributed-unsafe-injection-practices-endoscopy-clinic
February 27, 2019 - Government Resource
Acute Hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic—Nevada, 2007.
Citation Text:
Prevention C for DC and. Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic--Nevada, 2007.…
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psnet.ahrq.gov/issue/avoidable-iatrogenic-complications-urethral-catheterization-and-inadequate-intern-training
March 02, 2011 - Study
Avoidable iatrogenic complications of urethral catheterization and inadequate intern training in a tertiary-care teaching hospital.
Citation Text:
Thomas AZ, Giri SK, Meagher D, et al. Avoidable iatrogenic complications of urethral catheterization and inadequate intern training i…
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psnet.ahrq.gov/issue/advancing-nursing-home-quality-through-quality-improvement-itself
November 28, 2018 - Commentary
Advancing nursing home quality through quality improvement itself.
Citation Text:
Werner RM, Konetzka RT. Advancing Nursing Home Quality Through Quality Improvement Itself. Health Aff. 2010;29(1):81-86. doi:10.1377/hlthaff.2009.0555.
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psnet.ahrq.gov/issue/defining-patient-safety-events-inpatient-psychiatry
January 30, 2019 - Study
Defining patient safety events in inpatient psychiatry.
Citation Text:
Marcus SC, Hermann R, Cullen SW. Defining Patient Safety Events in Inpatient Psychiatry. J Patient Saf. 2018;17(8):e1452-e1457. doi:10.1097/PTS.0000000000000520.
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www.ahrq.gov/news/newsroom/case-studies/cquips0901.html
October 01, 2014 - New York City Uses AHRQ Patient Safety Culture Survey to Reduce Patient Harm
Search All Impact Case Studies
November 2008
The New York City Health and Hospitals Corporation (HHC) has integrated the use of AHRQ's Hospital Survey on Patient Safety Culture as a core component of its corporate-wide patient sa…
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psnet.ahrq.gov/issue/raising-awareness-inpatient-nursing-staff-about-medication-errors
February 15, 2011 - Study
Raising the awareness of inpatient nursing staff about medication errors.
Citation Text:
Elnour AA, Ellahham NH, Qassas HIA. Raising the awareness of inpatient nursing staff about medication errors. Pharm World Sci. 2008;30(2):182-90.
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psnet.ahrq.gov/issue/effect-health-information-technology-quality-us-hospitals
September 27, 2010 - Study
The effect of health information technology on quality in U.S. hospitals.
Citation Text:
McCullough JS, Casey M, Moscovice I, et al. The effect of health information technology on quality in U.S. hospitals. Health Aff (Millwood). 2010;29(4):647-654. doi:10.1377/hlthaff.2010.0155.
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psnet.ahrq.gov/issue/role-checklists-and-human-factors-improved-patient-safety-plastic-surgery
November 02, 2016 - Commentary
The role of checklists and human factors for improved patient safety in plastic surgery.
Citation Text:
Oppikofer C, Schwappach DLB. The Role of Checklists and Human Factors for Improved Patient Safety in Plastic Surgery. Plast Reconstr Surg. 2017;140(6):812e-817e. doi:10.1097…
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psnet.ahrq.gov/issue/causes-near-misses-critical-care-neonates-and-children
July 19, 2023 - Study
Causes of near misses in critical care of neonates and children.
Citation Text:
Tourgeman-Bashkin O, Shinar D, Zmora E. Causes of near misses in critical care of neonates and children. Acta Paediatr. 2008;97(3):299-303. doi:10.1111/j.1651-2227.2007.00616.x.
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psnet.ahrq.gov/issue/high-cost-low-frequency-events-anatomy-and-economics-surgical-mishaps
October 19, 2022 - Study
Classic
The high cost of low-frequency events: the anatomy and economics of surgical mishaps.
Citation Text:
Couch NP, Tilney NL, Rayner AA, et al. The high cost of low-frequency events: the anatomy and economics of surgical mishaps. N Engl J Med. 1981;3…
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psnet.ahrq.gov/issue/safety-home-healthcare-sector-development-new-household-safety-checklist
July 29, 2020 - Study
Safety in the home healthcare sector: development of a new household safety checklist.
Citation Text:
Gershon RRM, Dailey M, Magda LA, et al. Safety in the home healthcare sector: development of a new household safety checklist. J Patient Saf. 2012;8(2):51-9. doi:10.1097/PTS.0b0…
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psnet.ahrq.gov/issue/analysis-human-performance-deficiencies-associated-surgical-adverse-events
April 15, 2016 - Study
Emerging Classic
Analysis of human performance deficiencies associated with surgical adverse events.
Citation Text:
Suliburk JW, Buck QM, Pirko CJ, et al. Analysis of Human Performance Deficiencies Associated With Surgical Adverse Events. JAMA Netw Open. 2…
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psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-reducing-risk-harm
November 15, 2011 - Review
Patient safety and quality improvement: reducing risk of harm.
Citation Text:
Leonard M. Patient Safety and Quality Improvement: Reducing Risk of Harm. Pediatr Rev. 2015;36(10):448-56; quiz 457-8. doi:10.1542/pir.36-10-448.
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psnet.ahrq.gov/issue/how-do-simulated-error-experiences-impact-attitudes-related-error-prevention
October 19, 2022 - Study
How do simulated error experiences impact attitudes related to error prevention?
Citation Text:
Breitkreuz KR, Dougal RL, Wright MC. How Do Simulated Error Experiences Impact Attitudes Related to Error Prevention? Simul Healthc. 2016;11(5):323-333.
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psnet.ahrq.gov/issue/multi-disciplinary-approach-medication-safety-and-implication-nursing-education-and-practice
September 26, 2018 - Study
A multi-disciplinary approach to medication safety and the implication for nursing education and practice.
Citation Text:
Adhikari R, Tocher J, Smith P, et al. A multi-disciplinary approach to medication safety and the implication for nursing education and practice. Nurse Educ To…
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psnet.ahrq.gov/issue/spoons-systematically-bias-dosing-liquid-medicine
November 03, 2015 - Study
Spoons systematically bias dosing of liquid medicine.
Citation Text:
Wansink B, van Ittersum K. Spoons systematically bias dosing of liquid medicine. Ann Intern Med. 2010;152(1):66-7. doi:10.7326/0003-4819-152-1-201001050-00024.
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psnet.ahrq.gov/issue/point-care-testing-error-sources-and-amplifiers-taxonomy-prevention-strategies-and-detection
January 08, 2016 - Study
Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection monitors.
Citation Text:
Meier FA, Jones BA. Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection monitors. Arch Pathol Lab Med. 2005…
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psnet.ahrq.gov/issue/we-are-going-name-names-and-call-you-out-improving-team-academic-operating-room-environment
September 23, 2020 - Study
We are going to name names and call you out! Improving the team in the academic operating room environment.
Citation Text:
Bodor R, Nguyen BJ, Broder K. We Are Going to Name Names and Call You Out! Improving the Team in the Academic Operating Room Environment. Ann Plast Surg. 2017;…
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psnet.ahrq.gov/issue/practice-gaps-patient-safety-among-dermatology-residents-and-their-teachers-survey-study
August 19, 2009 - Study
Practice gaps in patient safety among dermatology residents and their teachers: a survey study of dermatology residents.
Citation Text:
Swary JH, Stratman EJ. Practice gaps in patient safety among dermatology residents and their teachers: a survey study of dermatology residents. JA…