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psnet.ahrq.gov/issue/sbar-shared-mental-model-improving-communication-between-clinicians
January 02, 2017 - Study
SBAR: a shared mental model for improving communication between clinicians.
Citation Text:
Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32(3):167-75.
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/woods-k-et-al-2000
January 01, 2000 - Woods K et al. 2000 "Sickle cell disease telemedicine network for rural outreach."
Reference
Woods KF, Johnson JA, Kutlar A, et al. Sickle cell disease telemedicine network for rural outreach. J Telemed Telecare 2000;6(5):285-290.
Abstract
"The Medical College of Georgia (MCG) Sickle Cell Cent…
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psnet.ahrq.gov/issue/start-using-checklist-pronto-recommendation-standard-review-process-chemotherapy-orders
March 04, 2015 - Commentary
Start using a checklist, PRONTO: recommendation for a standard review process for chemotherapy orders.
Citation Text:
Crandell BC, Bates JS, Grgic T. Start using a checklist, PRONTO: Recommendation for a standard review process for chemotherapy orders. J Oncol Pharm Pract. 201…
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx
Spotlight
The Dose Makes the Poison: Medication Error During
Procedural Sedation in the Pediatric Emergency
Department
Source and Credits
• This presentation is based on the April 2023 AH…
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psnet.ahrq.gov/node/49808/psn-pdf
October 01, 2017 - High-Risk Medications, High-Risk Transfers
October 1, 2017
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
The Case
A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/cesarean-birth-future_research.pdf
August 09, 2012 - United States, obstetric data systems both within and across hospitals “remain
rudimentary and lack standardization … Stakeholders identified the importance of standardization of
definitions as well as methods for measuring … United States, obstetric data systems both within and across hospitals “remain
rudimentary and lack standardization
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-report-testing-machine-learning-tool-chronic-pain.pdf
November 01, 2020 - (Table 5), suggesting that simulated updates can be
used to establish machine learning performance standards
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digital.ahrq.gov/ahrq-funded-projects/integris-telewoundcare-network/annual-summary/2008
January 01, 2008 - INTEGRIS Telewoundcare Network - 2008
Project Name
INTEGRIS Telewoundcare Network
Principal Investigator
Bryant, Charles
Organization
Integris Health, Inc.
Funding Mechanism
RFA: HS04-011: Transforming Health Care Quality through Information Technology (THQIT)
…
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/reid.html
October 01, 2015 - Transforming Primary Care: Evaluating the Spread of Group Health’s Medical Home
Principal Investigator: Robert Reid, MD, MPH, PhD
Institution: Group Health Cooperative
AHRQ Grant Number: R18 HS019129
Number and Type of Practices
This project included 26 practices in an integrated…
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www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/newman-toker-summit2016.pdf
September 28, 2016 - Use of Data and Measurement in Improving Diagnostic Safety
AHRQ Research Summit, September 28, 2016
Use of Data and Measurement in
Improving Diagnostic Safety
David E. Newman-Toker, MD PhD
Associate Professor of Neurology
Johns Hopkins University School of Medicine
Johns Hopkins Bloomberg School of Public Heal…
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meps.ahrq.gov/data_files/publications/rf44/rf44.pdf
October 01, 2019 - Research Findings #44: Retail Drug Prices, Out-of-Pocket Costs, and Discounts and Markups Relative to List Prices: Trends and Differences by Drug Type and Insurance Status, 2011 to 2016
Retail Drug Prices, Out-of-Pocket Costs, and
Discounts and Markups Relative to List Prices:
Trends and Differences by Drug T…
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psnet.ahrq.gov/node/60556/psn-pdf
June 03, 2020 - The impact of technology on prescribing errors in
pediatric intensive care: a before and after study.
June 3, 2020
Howlett MM, Butler E, Lavelle KM, et al. The impact of technology on prescribing errors in pediatric
intensive care: a before and after study. Appl Clin Inform. 2020;11(02). doi:10.1055/s-0040-1709508.…
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psnet.ahrq.gov/node/836772/psn-pdf
March 23, 2022 - Error reduction in trauma care: lessons from an
anonymized, national, multicenter mortality reporting
system.
March 23, 2022
Hamad DM, Mandell SP, Stewart RM, et al. Error reduction in trauma care: Lessons from an anonymized,
national, multicenter mortality reporting system. J Trauma Acute Care Surg. 2022;92(3):47…
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psnet.ahrq.gov/node/46894/psn-pdf
June 20, 2018 - Smart pump custom concentrations without hard "low
concentration" alerts can lead to patient harm.
June 20, 2018
ISMP Medication Safety Alert! Acute Care Edition. May 31, 2018;23:1-4.
https://psnet.ahrq.gov/issue/smart-pump-custom-concentrations-without-hard-low-concentration-alerts-can-
lead-patient-harm
Smart p…
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psnet.ahrq.gov/node/44321/psn-pdf
July 08, 2015 - Move toward full use of metric dosing: eliminate dosage
cups that measure liquids in fluid drams. Use cups that
measure mL.
July 8, 2015
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American
Society of Health-System Pharmacists. June 30, 2015.
https://psnet.ahrq.gov/…
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/video/sbar-inpatient-guide.pdf
June 02, 2025 - TeamSTEPPS Video Debrief Guide: SBAR on Inpatient Medical Unit
TeamSTEPPS Video Debrief Guide: SBAR on Inpatient
Medical Unit
Video Objective
To demonstrate each step of SBAR and emphasize the importance of standard communication and use
of the tool.
TeamSTEPPS Tool or Concept
SBAR.
Brief Video Descriptio…
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www.ahrq.gov/patient-safety/settings/emergency-dept/index.html
July 01, 2025 - AHRQ's Quality & Patient Safety Programs by Setting: Emergency Department
Design Guidelines for Trauma Rooms is an evidence-based set of recommendations covering 27 key design elements for trauma room and trauma center design planning. These actionable insights support architects, clinicians, and policymakers …
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www.ahrq.gov/hai/quality/tools/cauti-ltc/prevention-skills.html
March 01, 2017 - Practice General Infection Prevention Skills
A Unit Guide To Infection Prevention for Long-Term Care Staff ( PDF , 2.97 MB)
This guide provides frontline and other staff with basic knowledge about long-term care facility infection prevention guidelines.
Standard- and Transmission-Based Precautions
Educ…
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psnet.ahrq.gov/node/37706/psn-pdf
December 23, 2016 - Preventing pediatric medication errors.
December 23, 2016
Preventing pediatric medication errors. Sentinel event alert. 2008;39:1-4.
https://psnet.ahrq.gov/issue/preventing-pediatric-medication-errors
The Joint Commission issues sentinel event alerts one to two times yearly to highlight areas of high risk
and to p…
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psnet.ahrq.gov/node/866271/psn-pdf
July 10, 2024 - A taxonomy for advancing systematic error analysis in
multi-site electronic health record-based clinical concept
extraction.
July 10, 2024
Fu S, Wang L, He H, et al. A taxonomy for advancing systematic error analysis in multi-site electronic
health record-based clinical concept extraction. J Am Med Inform Assoc. 2…