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psnet.ahrq.gov/issue/care-transition-trauma-patients-processes-articulation-work-and-after-handoff
June 22, 2022 - Study
Care transition of trauma patients: processes with articulation work before and after handoff.
Citation Text:
Wooldridge AR, Carayon P, Hoonakker PLT, et al. Care transition of trauma patients: processes with articulation work before and after handoff. Appl Ergon. 2022;98:103606. d…
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psnet.ahrq.gov/issue/scoping-review-adverse-incidents-research-aged-care-homes-learnings-gaps-and-challenges
November 18, 2020 - Review
A scoping review of adverse incidents research in aged care homes: learnings, gaps, and challenges.
Citation Text:
St Clair B, Jorgensen M, Nguyen A, et al. A scoping review of adverse incidents research in aged care homes: learnings, gaps, and challenges. Gerontol Geriatr Med. 20…
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psnet.ahrq.gov/issue/applying-medications-transitions-and-clinical-handoffs-toolkit-rural-primary-care-clinic
August 04, 2021 - Study
Applying the Medications at Transitions and Clinical Handoffs Toolkit in a rural primary care clinic: implications for nursing, patients, and caregivers.
Citation Text:
Jarrett T, Cochran J, Baus A. Applying the Medications at Transitions and Clinical Handoffs Toolkit in a rural pr…
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psnet.ahrq.gov/issue/teamgains-tool-structured-debriefings-simulation-based-team-trainings
October 08, 2016 - Study
TeamGAINS: a tool for structured debriefings for simulation-based team trainings.
Citation Text:
Kolbe M, Weiss M, Grote G, et al. TeamGAINS: a tool for structured debriefings for simulation-based team trainings. BMJ Qual Saf. 2013;22(7):541-53. doi:10.1136/bmjqs-2012-000917.
Co…
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hcup-us.ahrq.gov/db/state/siddist/siddist_filecompmo.jsp
June 01, 2024 - SID File Composition - Missouri
An official website of the Department of Health & Human Services
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Careers
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FAQs
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psnet.ahrq.gov/issue/sources-medication-omissions-among-hospitalized-older-adults-polypharmacy
January 18, 2023 - Study
Sources of medication omissions among hospitalized older adults with polypharmacy.
Citation Text:
Shah AS, Hollingsworth EK, Shotwell MS, et al. Sources of medication omissions among hospitalized older adults with polypharmacy. J Am Geriatr Soc. 2022;70(4):1180-1189. doi:10.1111/jg…
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hcup-us.ahrq.gov/db/state/siddist/siddist_filecompsd.jsp
August 01, 2012 - SID File Composition - South Dakota
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contact Us
Espanol
FAQs
Email Updates
…
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psnet.ahrq.gov/issue/caregiver-and-clinician-perspectives-discharge-medication-counseling-qualitative-study
January 31, 2024 - Study
Caregiver and clinician perspectives on discharge medication counseling: a qualitative study.
Citation Text:
Carroll AR, Schlundt D, Bonnet K, et al. Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. Hosp Pediatr. 2023;13(4):325-342. doi:…
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psnet.ahrq.gov/issue/intensive-care-unit-nurse-staffing-and-risk-complications-after-abdominal-aortic-surgery
December 02, 2020 - Study
Classic
Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery.
Citation Text:
Pronovost PJ, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surge…
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psnet.ahrq.gov/issue/unfinished-nursing-care-missed-care-and-implicitly-rationed-care-state-science-review
May 08, 2024 - Review
Unfinished nursing care, missed care, and implicitly rationed care: state of the science review.
Citation Text:
Jones TL, Hamilton P, Murry N. Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. Int J Nurs Stud. 2015;52(6):1121-1137. do…
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psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review
January 06, 2018 - Review
Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review.
Citation Text:
Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):410-416. doi:10.7326/0003-…
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psnet.ahrq.gov/issue/randomised-controlled-trial-effect-continuous-electronic-physiological-monitoring-adverse
August 04, 2021 - Study
A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients.
Citation Text:
Watkinson PJ, Barber VS, Price JD, et al. A randomised controlled trial of the effect of continuous e…
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psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-long-term-care-and-its-relationship-probable-delirium
September 23, 2020 - Study
Potentially inappropriate prescribing in long-term care and its relationship with probable delirium.
Citation Text:
Webber C, Milani C, Bjerre LM, et al. Potentially inappropriate prescribing in long-term care and its relationship with probable delirium. J Am Med Dir Assoc. 2024;25…
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psnet.ahrq.gov/issue/association-clinical-specialty-symptoms-burnout-and-career-choice-regret-among-us-resident
December 21, 2018 - Study
Classic
Association of clinical specialty with symptoms of burnout and career choice regret among US resident physicians.
Citation Text:
Dyrbye LN, Burke SE, Hardeman RR, et al. Association of Clinical Specialty With Symptoms of Burnout and Career Choice R…
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psnet.ahrq.gov/issue/how-hospital-leaders-contribute-patient-safety-through-development-trust
January 22, 2014 - Study
How hospital leaders contribute to patient safety through the development of trust.
Citation Text:
Auer C, Schwendimann R, Koch R, et al. How hospital leaders contribute to patient safety through the development of trust. J Nurs Adm. 2014;44(1):23-9. doi:10.1097/NNA.00000000000000…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Vane.pdf
February 01, 2005 - The realization that new technical skills must be taught in a fast paced,
uncomfortable, dangerous deployed … a constant pace for 293 days, the
leadership needs to recognize how valuable the clinical staff’s skills … a constant pace for 293 days, the
leadership needs to recognize how valuable the clinical staff’s skills
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Zhang.pdf
January 01, 2004 - process of identifying the characteristics of existing and
potential users, such as their expertise and skills … educational
background; cognitive capacities and limitations; perceptual variations; age-
related skills … Multiple Levels of
Analysis
User Analysis: identify characteristics
of users, such as expertise and skills
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psnet.ahrq.gov/node/33697/psn-pdf
June 01, 2010 - Issues Patient Issues
Environmental
System Issues
Risk Factors
Experience
Fatigue
Knowledge and skills
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www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/guide-staffing-during-COVID19.pdf
June 02, 2025 - Staffing During the COVID-19 Pandemic: A Guide for Nursing Home Leaders
Staffing During the COVID-19 Pandemic:
A Guide for Nursing Home Leaders
Introduction
This resource guide was written by and for directors of nursing, administrators, and other nursing home
leaders. It outlines steps to reduce or elimi…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/129-ss-blank-lfd.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects Tool
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
What Is a Defect?
A defect is any clinical or operational event or situation that you would not want to happen again. This could include incidents…