-
www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/getting-started-resource-guide.pdf
March 01, 2023 - -CRCP-Crucial Conversations with Med Providers and Hosp
Admins.pptx
This PowerPoint presentation suggests … /wohp/Documents/mc3-clinical-champions-mcneil.pdf
This PowerPoint, created by Liverpool Hospital, suggests
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/lung-cancer-nonsurgical-therapies_disposition-comments.pdf
June 12, 2013 - survey results show that nearly 40 percent of solo
practitioners treat patients with SBRT, which suggests … SBRT is not
as widely available as 3DRT or IMRT, but our
literature review suggests there has been
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/trauma-interventions-maltreatment-child_disposition-comments.pdf
April 15, 2013 - challenging to do) and so on, but the sheer volume of factors that
would make for a stronger research base suggests … published literature makes the contribution clinically meaningful on the one hand, but
on the other hand, suggests
-
psnet.ahrq.gov/node/44380/psn-pdf
October 26, 2018 - From Safety-I to Safety-II: A White Paper.
October 26, 2018
Hollnagel E, Wears RL, Braithwaite J. Middelfart, Denmark: Resilient Health Care Net; 2015.
https://psnet.ahrq.gov/issue/safety-i-safety-ii-white-paper
To enhance patient safety, researchers must consider complexity in health care settings. This white pape…
-
psnet.ahrq.gov/node/43366/psn-pdf
March 04, 2015 - Safety of medication use in primary care.
March 4, 2015
Olaniyan JO, Ghaleb M, Dhillon S, et al. Safety of medication use in primary care. Int J Pharm Pract.
2015;23(1):3-20. doi:10.1111/ijpp.12120.
https://psnet.ahrq.gov/issue/safety-medication-use-primary-care
This systematic review found that incidence rates of…
-
psnet.ahrq.gov/node/44445/psn-pdf
September 16, 2015 - Understanding nurses' and physicians' fear of
repercussions for reporting errors: clinician
characteristics, organization demographics, or leadership
factors?
September 16, 2015
Castel ES, Ginsburg LR, Zaheer S, et al. Understanding nurses' and physicians' fear of repercussions for
reporting errors: clinician cha…
-
psnet.ahrq.gov/node/72865/psn-pdf
March 17, 2021 - 5 pandemic mistakes we keep repeating. We can learn
from our failures.
March 17, 2021
Zeynep Tufekci. The Atlantic. February 26, 2021
https://psnet.ahrq.gov/issue/5-pandemic-mistakes-we-keep-repeating-we-can-learn-our-failures
Failures in communication have impacts on patients, teams, organizations and society. Th…
-
psnet.ahrq.gov/node/847060/psn-pdf
January 01, 2001 - The Emperor’s New Clothes: Or Whatever Happened To
“Human Error”?
January 1, 2001
Hollnagel E, Amalberti R. Chapter In: Dekker SWA, ed. Proceedings of the 4th International
Workshop on Human Error, Safety and Systems Development. Linköping Sweden: Linköping University;
2001.
https://psnet.ahrq.gov/issu…
-
psnet.ahrq.gov/node/73678/psn-pdf
September 08, 2021 - A report of information technology and health
deficiencies in U.S. nursing homes.
September 8, 2021
Alexander GL, Madsen RW. A report of information technology and health deficiencies in U.S. nursing
homes. J Patient Saf. 2021;17(6):e483-e489. doi:10.1097/pts.0000000000000390.
https://psnet.ahrq.gov/issue/report-i…
-
psnet.ahrq.gov/node/45372/psn-pdf
November 18, 2016 - Determinants of patient–oncologist prognostic
discordance in advanced cancer.
November 18, 2016
Gramling R, Fiscella K, Xing G, et al. Determinants of Patient-Oncologist Prognostic Discordance in
Advanced Cancer. JAMA Oncol. 2016;2(11):1421-1426. doi:10.1001/jamaoncol.2016.1861.
https://psnet.ahrq.gov/issue/determ…
-
psnet.ahrq.gov/node/33927/psn-pdf
June 23, 2015 - Errors, incidents and accidents in anaesthetic practice.
June 23, 2015
Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and
accidents in anaesthetic practice. Anaesth Intensive Care. 1993;21(5):506-19.
https://psnet.ahrq.gov/issue/errors-incidents-and-accidents-anae…
-
psnet.ahrq.gov/node/45633/psn-pdf
December 21, 2016 - Lost in translation: medication labeling for immigrant
families.
December 21, 2016
Smith MCJ, Yin S, Sanders LM. Lost in translation: Medication labeling for immigrant families. J Am Pharm
Assoc (2003). 2016;56(6):677-679. doi:10.1016/j.japh.2016.07.002.
https://psnet.ahrq.gov/issue/lost-translation-medication-lab…
-
psnet.ahrq.gov/node/44251/psn-pdf
January 13, 2016 - Early impact of the 2011 ACGME duty hour regulations on
surgical outcomes.
January 13, 2016
Scally CP, Ryan AM, Thumma JR, et al. Early impact of the 2011 ACGME duty hour regulations on surgical
outcomes. Surgery. 2015;158(6):1453-61. doi:10.1016/j.surg.2015.05.002.
https://psnet.ahrq.gov/issue/early-impact-2011-a…
-
psnet.ahrq.gov/node/35749/psn-pdf
May 09, 2014 - Chemotherapy dose limits set by users of a computer
order entry system.
May 9, 2014
DuBeshter B; Griggs J; Angel C; Loughner J.
https://psnet.ahrq.gov/issue/chemotherapy-dose-limits-set-users-computer-order-entry-system
To avoid excessive dosing of chemotherapeutic agents, standardized dose limits must be agreed u…
-
psnet.ahrq.gov/node/47534/psn-pdf
November 21, 2018 - Resident hesitation in the operating room: does
uncertainty equal incompetence?
November 21, 2018
Ott M, Schwartz A, Goldszmidt M, et al. Resident hesitation in the operating room: does uncertainty equal
incompetence? Med Educ. 2018;52(8):851-860. doi:10.1111/medu.13530.
https://psnet.ahrq.gov/issue/resident-hesit…
-
psnet.ahrq.gov/node/60897/psn-pdf
January 01, 2022 - Association between surgeon technical skills and patient
outcomes.
September 9, 2020
Stulberg JJ, Huang R, Kreutzer L, et al. Association Between Surgeon Technical Skills and Patient
Outcomes. JAMA Surg. 2022;157(3):219-220. doi:10.1001/jamasurg.2020.3007.
https://psnet.ahrq.gov/issue/association-between-surgeon-t…
-
psnet.ahrq.gov/node/47043/psn-pdf
January 01, 2019 - Association of nurse engagement and nurse staffing on
patient safety.
December 6, 2018
Carthon MB, Hatfield L, Plover C, et al. Association of nurse engagement and nurse staffing on patient
safety. J Nurs Care Qual. 2019;34(1):40-46. doi:10.1097/NCQ.0000000000000334.
https://psnet.ahrq.gov/issue/association-nurse-…
-
psnet.ahrq.gov/node/36027/psn-pdf
March 28, 2011 - Medical injuries among hospitalized children.
March 28, 2011
Meurer JR, Yang H, Guse CE, et al. Medical injuries among hospitalized children. Qual Saf Health Care.
2006;15(3):202-7.
https://psnet.ahrq.gov/issue/medical-injuries-among-hospitalized-children
This AHRQ–funded study applied new screening criteria to ca…
-
psnet.ahrq.gov/node/45406/psn-pdf
November 01, 2016 - Errors and nonadherence in pediatric oral chemotherapy
use.
November 1, 2016
Walsh KE, Ryan J, Daraiseh N, et al. Errors and Nonadherence in Pediatric Oral Chemotherapy Use.
Oncology. 2016;91(4):231-236.
https://psnet.ahrq.gov/issue/errors-and-nonadherence-pediatric-oral-chemotherapy-use
Medication errors and non…
-
psnet.ahrq.gov/node/34086/psn-pdf
May 27, 2011 - Overcoming barriers to adopting and implementing
computerized physician order entry systems in U.S.
hospitals.
May 27, 2011
Poon EG, Blumenthal D, Jaggi T, et al. Overcoming barriers to adopting and implementing computerized
physician order entry systems in U.S. hospitals. Health Aff (Millwood). 2004;23(4):184-90.…