-
psnet.ahrq.gov/node/60194/psn-pdf
April 01, 2020 - Do you know what doses are being programmed in the
OR? Make it an expectation to use smart infusion pumps
with DERS.
April 1, 2020
Do you know what doses are being programmed in the OR? Make it an expectation to use smart infusion
pumps with DERS. ISMP Medication Safety Alert! Acute care edition!. 25(5):1-5.
http…
-
psnet.ahrq.gov/node/44970/psn-pdf
May 09, 2017 - Analysis of prescribers' notes in electronic prescriptions
in ambulatory practice.
May 9, 2017
Dhavle AA, Yang Y, Rupp MT, et al. Analysis of Prescribers' Notes in Electronic Prescriptions in
Ambulatory Practice. JAMA Intern Med. 2016;176(4):463-70. doi:10.1001/jamainternmed.2015.7786.
https://psnet.ahrq.gov/issue…
-
psnet.ahrq.gov/node/854630/psn-pdf
October 18, 2023 - Physician behaviors associated with increased physician
and nurse communication during bedside
interdisciplinary rounds.
October 18, 2023
Huang KX, Chen CK, Pessegueiro AM, et al. Physician behaviors associated with increased physician and
nurse communication during bedside interdisciplinary rounds. J Hosp Med. 20…
-
psnet.ahrq.gov/node/851647/psn-pdf
July 26, 2023 - Statewide perinatal quality improvement, teamwork, and
communication activities in Oklahoma and Texas.
July 26, 2023
Stierman EK, O'Brien BT, Stagg J, et al. Statewide perinatal quality improvement, teamwork, and
communication activities in Oklahoma and Texas. Qual Manag Health Care. 2023;32(3):177-188.
doi:10.109…
-
psnet.ahrq.gov/node/47198/psn-pdf
August 22, 2018 - Health IT Safe Practices for Closing the Loop.
August 22, 2018
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018.
https://psnet.ahrq.gov/issue/health-it-safe-practices-closing-loop
Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal…
-
psnet.ahrq.gov/node/60540/psn-pdf
November 01, 2016 - Quality improvement initiatives lead to reduction in
nulliparous term singleton vertex cesarean delivery rate.
November 1, 2016
Vadnais MA, Hacker MR, Shah NT, et al. Quality improvement initiatives lead to reduction in nulliparous
term singleton vertex cesarean delivery rate. Jt Comm J Qual Patient Saf. 2016;43(2)…
-
psnet.ahrq.gov/node/842421/psn-pdf
January 11, 2023 - Weight and size descriptors for drug dosing: too many
options and too many errors.
January 11, 2023
Erstad BL, Romero AV, Barletta JF. Weight and size descriptors for drug dosing: Too many options and too
many errors. Am J Health Syst Pharm. 2023;80(2):87-91. doi:10.1093/ajhp/zxac283.
https://psnet.ahrq.gov/issue/…
-
psnet.ahrq.gov/node/41211/psn-pdf
January 03, 2017 - He thought the "lady in the door" was the "lady in the
window": a qualitative study of patient identification
practices.
January 3, 2017
Phipps E, Turkel M, Mackenzie ER, et al. He thought the "lady in the door" was the "lady in the window": a
qualitative study of patient identification practices. Jt Comm J Qual P…
-
psnet.ahrq.gov/node/39533/psn-pdf
May 25, 2015 - The relationship between patient safety culture and the
implementation of organizational patient safety defences
at emergency departments.
May 25, 2015
van Noord I, de Bruijne M, Twisk JWR. The relationship between patient safety culture and the
implementation of organizational patient safety defences at emergency…
-
psnet.ahrq.gov/node/42980/psn-pdf
February 17, 2017 - Disclosing adverse events to patients: international
norms and trends.
February 17, 2017
Wu AW, McCay L, Levinson W, et al. Disclosing Adverse Events to Patients: International Norms and
Trends. J Patient Saf. 2017;13(1):43-49. doi:10.1097/PTS.0000000000000107.
https://psnet.ahrq.gov/issue/disclosing-adverse-event…
-
psnet.ahrq.gov/node/40128/psn-pdf
January 12, 2011 - Impact of a comprehensive safety initiative on patient-
controlled analgesia errors.
January 12, 2011
Paul JE, Bertram B, Antoni K, et al. Impact of a comprehensive safety initiative on patient-controlled
analgesia errors. Anesthesiology. 2010;113(6):1427-32. doi:10.1097/ALN.0b013e3181fcb427.
https://psnet.ahrq.go…
-
psnet.ahrq.gov/node/37092/psn-pdf
August 21, 2008 - Enhancing patient safety during pediatric sedation: the
impact of simulation-based training of
nonanesthesiologists.
August 21, 2008
Shavit I, Keidan I, Hoffmann Y, et al. Enhancing patient safety during pediatric sedation: the impact of
simulation-based training of nonanesthesiologists. Arch Pediatr Adolesc Med. …
-
psnet.ahrq.gov/node/47454/psn-pdf
May 29, 2019 - Development and implementation of a subcutaneous
insulin pen label bar code scanning protocol to prevent
wrong-patient insulin pen errors.
May 29, 2019
MacMaster HW, Gonzalez S, Maruoka A, et al. Development and Implementation of a Subcutaneous
Insulin Pen Label Bar Code Scanning Protocol to Prevent Wrong-Patient …
-
psnet.ahrq.gov/node/41951/psn-pdf
September 07, 2016 - The impact of drug shortages on children with
cancer—the example of mechlorethamine.
September 7, 2016
Metzger ML, Billett A, Link MP. The impact of drug shortages on children with cancer--the example of
mechlorethamine. N Engl J Med. 2012;367(26):2461-2463. doi:10.1056/NEJMp1212468.
https://psnet.ahrq.gov/issue/i…
-
psnet.ahrq.gov/node/44580/psn-pdf
January 13, 2016 - Computerized Prescriber Order Entry Medication Safety
(CPOEMS): Uncovering and Learning From Issues and
Errors.
January 13, 2016
Brigham and Women's Hospital, Harvard Medical School, Partners HealthCare. Silver Spring, MD: US
Food and Drug Administration; December 15, 2015.
https://psnet.ahrq.gov/issue/computeriz…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/amermanslides.pdf
June 02, 2025 - Using the AHRQ Pharmacy Survey on Patient Safety Culture
Safety Survey
Dawn Amerman
Manager
Dexter Pharmacy and Village Pharmacy II
Reasons for Taking the Survey
• Provided staff with an opportunity to give
uncensored feedback
• Offered staff a sense of being part of the
solutions
• Let staff know t…
-
psnet.ahrq.gov/node/837799/psn-pdf
August 10, 2022 - Effect of a pharmacy-based centralized intravenous
admixture service on the prevalence of medication errors:
a before-and-after study.
August 10, 2022
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Effect of a pharmacy-based centralized intravenous
admixture service on the prevalence of medication errors: a befo…
-
psnet.ahrq.gov/node/853432/psn-pdf
September 13, 2023 - Healthcare leaders' and elected politicians' approach to
support-systems and requirements for complying with
quality and safety regulation in nursing homes - a case
study.
September 13, 2023
Magerøy MR, Braut GS, Macrae C, et al. Healthcare leaders’ and elected politicians’ approach to support-
systems and requir…
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/nyp-webinar-ginsberg.pdf
June 02, 2025 - Implementing the New CAHPS® Protocol for Obtaining Patient Comments About Their Care
AHRQ and AHRQ’s CAHPS®
Program
Caren Ginsberg, Ph.D.
Director, CAHPS Division, Center for Quality
Improvement and Patient Safety
Agency for Healthcare Research and Quality
www.ahrq.gov/cahps
AHRQ’s Core Competencies
Resea…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/umich-slides.ppt
May 20, 2012 - HHCEB Presentation
*
VTE Prevention:
An Institution-wide Initiative
University of Michigan
Caprini VTE risk assessment
May 20, 2012
Marc Moote, PA-C
Chief Physician Assistant
University of Michigan Health System
*
*
Key Strategies
Scope: ALL adult inpatients
Standardized VTE Protocol – Caprini model
Mandato…