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8021. Executive Summary | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/vtguide/guidesum.html
      March 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism Executive Summary Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. Analyze Care Delivery Chapter 3. Outline the…

8022. Health Information Technology in Ambulatory Care Settings: Effects on Quality and Disparities | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/health-information-technology-ambulatory-care-settings-effects-quality-and-disparities
      January 01, 2023 - Health Information Technology in Ambulatory Care Settings: Effects on Quality and Disparities Project Final Report ( PDF , 106.85 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not …

8023. The problem with root cause analysis. | PSNet
      psnet.ahrq.gov/issue/problem-root-cause-analysis
      August 28, 2024 - Commentary The problem with root cause analysis. Citation Text: Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf. 2017;26(5):417-422. doi:10.1136/bmjqs-2016-005511. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML…

8024. Hospital safety climate and safety outcomes: is there a relationship in the VA? | PSNet
      psnet.ahrq.gov/issue/hospital-safety-climate-and-safety-outcomes-there-relationship-va
      October 14, 2009 - Study Hospital safety climate and safety outcomes: is there a relationship in the VA? Citation Text: Rosen AK, Singer SJ, Zhao S, et al. Hospital safety climate and safety outcomes: is there a relationship in the VA? Med Care Res Rev. 2010;67(5):590-608. doi:10.1177/1077558709356703. …

8025. Leadership Support | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-sustainability-centers-of-excellence5.html
      April 01, 2025 - Four Pillars for Sustainable Centers of Excellence Leadership Support Previous Page Next Page Table of Contents Four Pillars for Sustainable Centers of Excellence Introduction Center of Excellence Operations Alignment Integration Leadership Support Windows of Opportunity Conclusion A…

8026. Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes. | PSNet
      psnet.ahrq.gov/issue/excess-dosing-antiplatelet-and-antithrombin-agents-treatment-non-st-segment-elevation-acute
      November 10, 2015 - Study Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes. Citation Text: Alexander KP, Chen AY, Roe MT, et al. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acu…

8027. Intervening in interruptions: what exactly is the risk we are trying to manage? | PSNet
      psnet.ahrq.gov/issue/intervening-interruptions-what-exactly-risk-we-are-trying-manage
      July 20, 2022 - Review Intervening in interruptions: what exactly is the risk we are trying to manage? Citation Text: Gao J, Rae AJ, Dekker SWA. Intervening in Interruptions: What Exactly Is the Risk We Are Trying to Manage? J Patient Saf. 2021;17(7):e684-e688. doi:10.1097/PTS.0000000000000429. Copy C…

8028. Do words matter? Stigmatizing language and the transmission of bias in the medical record. | PSNet
      psnet.ahrq.gov/issue/do-words-matter-stigmatizing-language-and-transmission-bias-medical-record
      June 06, 2021 - Study Do words matter? Stigmatizing language and the transmission of bias in the medical record. Citation Text: P. Goddu A, O’Conor KJ, Lanzkron S, et al. Do words matter? Stigmatizing language and the transmission of bias in the medical record. J Gen Intern Med. 2018;33(5):685-691. doi:…

8029. A Clinical Decision Support Tool for Preventing Falls | Digital Healthcare Research
      digital.ahrq.gov/program-overview/research-stories/clinical-decision-support-tool-preventing-falls
      January 01, 2023 - A Clinical Decision Support Tool for Preventing Falls Theme: Optimizing Care Delivery for Clinicians Subtheme: Scaling Effective and Interoperable CDS to Improve Care and Decision Making Tools like ASPIRE that integrate fall prevention clinical decision support and patient resources may be…

8030. Patient-Centered CDS for Postpartum Hypertension Monitoring (pdf file)
      cdsic.ahrq.gov/sites/default/files/2023-02/Real%20World%20PC%20CDS_Patient-Centered%20CDS%20for%20Postpartum%20Hypertension%20Monitoring_508_Jan26.pdf
      January 01, 2023 - Patient-Centered CDS for Postpartum Hypertension Monitoring Patient-Centered CDS for Postpartum Hypertension Monitoring At age 42, Brittany McFarland was excited about her first pregnancy after over a year of trying to conceive. All was going well with the pregnancy until she developed preeclampsia in her third…

8031. The influence of organizational culture, climate and commitment on speaking up about medical errors. | PSNet
      psnet.ahrq.gov/issue/influence-organizational-culture-climate-and-commitment-speaking-about-medical-errors
      December 31, 2018 - Study Emerging Classic The influence of organizational culture, climate and commitment on speaking up about medical errors. Citation Text: Levine KJ, Carmody M, Silk KJ. The influence of organizational culture, climate and commitment on speaking up about medical…

8032. Creating highly reliable health care: how reliability-enhancing work practices affect patient safety in hospitals. | PSNet
      psnet.ahrq.gov/issue/creating-highly-reliable-health-care-how-reliability-enhancing-work-practices-affect-patient
      January 12, 2022 - Study Creating highly reliable health care: how reliability-enhancing work practices affect patient safety in hospitals. Citation Text: Vogus TJ, Iacobucci D. Creating Highly Reliable Health Care. ILR Review. 2016;69(4). doi:10.1177/0019793916642759. Copy Citation Format: D…

8033. The potential for improved teamwork to reduce medical errors in the emergency department. | PSNet
      psnet.ahrq.gov/issue/potential-improved-teamwork-reduce-medical-errors-emergency-department
      July 07, 2021 - Review Classic The potential for improved teamwork to reduce medical errors in the emergency department. Citation Text: Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg M…

8034. A systematic review of failures in handoff communication during intrahospital transfers. | PSNet
      psnet.ahrq.gov/issue/systematic-review-failures-handoff-communication-during-intrahospital-transfers
      November 03, 2015 - Review A systematic review of failures in handoff communication during intrahospital transfers. Citation Text: Ong M-S, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers. Jt Comm J Qual Patient Saf. 2011;37(6):274-284. Copy Citation …

8035. Beyond burnout: a physician wellness hierarchy designed to prioritize interventions at the systems level. | PSNet
      psnet.ahrq.gov/issue/beyond-burnout-physician-wellness-hierarchy-designed-prioritize-interventions-systems-level
      July 19, 2023 - Review Beyond burnout: a physician wellness hierarchy designed to prioritize interventions at the systems level. Citation Text: Shapiro DE, Duquette C, Abbott LM, et al. Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the Systems Level. Am J Med. 20…

8036. The application of the Global Trigger Tool: a systematic review. | PSNet
      psnet.ahrq.gov/issue/application-global-trigger-tool-systematic-review
      December 06, 2023 - Review The application of the Global Trigger Tool: a systematic review. Citation Text: Hibbert PD, Molloy CJ, Hooper TD, et al. The application of the Global Trigger Tool: a systematic review. Int J Qual Health Care. 2016;28(6):640-649. doi:10.1093/intqhc/mzw115. Copy Citation For…

8037. Stakeholder safety communication: patient and family reports on safety risks in hospitals. | PSNet
      psnet.ahrq.gov/issue/stakeholder-safety-communication-patient-and-family-reports-safety-risks-hospitals
      July 28, 2021 - Study Stakeholder safety communication: patient and family reports on safety risks in hospitals. Citation Text: Reader TW. Stakeholder safety communication: patient and family reports on safety risks in hospitals. J Risk Res. 2022;25(7):807-824. doi:10.1080/13669877.2022.2061036. Copy …

8038. Variation in detected adverse events using trigger tools: a systematic review and meta-analysis. | PSNet
      psnet.ahrq.gov/issue/variation-detected-adverse-events-using-trigger-tools-systematic-review-and-meta-analysis
      January 25, 2023 - Review Variation in detected adverse events using trigger tools: a systematic review and meta-analysis. Citation Text: Eggenschwiler LC, Rutjes AWS, Musy SN, et al. Variation in detected adverse events using trigger tools: a systematic review and meta-analysis. PLoS ONE. 2022;17(9):e0273…

8039. Time to take hearing loss seriously. | PSNet
      psnet.ahrq.gov/issue/time-take-hearing-loss-seriously
      September 23, 2020 - Commentary Time to take hearing loss seriously. Citation Text: Blustein J, Wallhagen MI, Weinstein BE, et al. Time to take hearing loss seriously. Jt Comm J Qual Patient Saf. 2019;46(1):53-58. doi:10.1016/j.jcjq.2019.10.003. Copy Citation Format: DOI Google Scholar BibTeX E…

8040. Impact of medical education on patient safety: finding the signal through the noise. | PSNet
      psnet.ahrq.gov/issue/impact-medical-education-patient-safety-finding-signal-through-noise
      December 31, 2018 - Commentary Impact of medical education on patient safety: finding the signal through the noise. Citation Text: Hwang J, Kelz RR. Impact of medical education on patient safety: finding the signal through the noise. BMJ Qual Saf. 2023;32(2):61-64. doi:10.1136/bmjqs-2022-015054. Copy Cita…