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  1. Evaluation Issues | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/issues.html
    August 01, 2022 - Demonstration Grants Final Evaluation Report Evaluation Issues Previous Page Next Page Table of Contents Demonstration Grants Final Evaluation Report Executive Summary Detailed Findings Evaluation Issues Contributions to Patient Safety and Medical Liability Lessons Learned From Implement…

  2. Steele AW et al. 2005 "The effect of automated alerts on provider ordering behavior in an outpatient setting." | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/experience-research/steele-aw-et
    January 01, 2023 - Steele AW et al. 2005 "The effect of automated alerts on provider ordering behavior in an outpatient setting." Reference Steele AW, Eisert S, Witter J, et al. The effect of automated alerts on provider ordering behavior in an outpatient setting. PLoS Med 2005;2(9):864-870. [Link] Abstract "B…

  3. Electronic Health Record Use, Work Environments, and Patient Outcomes | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/electronic-health-record-use-work-environments-and-patient-outcomes
    January 01, 2023 - Electronic Health Record Use, Work Environments, and Patient Outcomes Project Final Report ( PDF , 512.06 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 necessarily represent th…

  4. Simon SR et al. 2006 "Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people." | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/simon-sr-et-al-2006
    January 01, 2006 - Simon SR et al. 2006 "Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people." Reference Simon SR, Smith DH, Feldstein AC, et al. Computerized prescribing alerts and group academic detailing to reduce the use of potential…

  5. New Tools Help Health Providers Reduce Patients' Risk of Falls | Agency for Healthcare Research and Quality

    www.ahrq.gov/patients-consumers/patient-involvement/patients-risk-of-falls.html
    September 01, 2015 - New Tools Help Health Providers Reduce Patients' Risk of Falls For older adults, falls are serious, no matter the setting. These falls can cause bone fractures, disability, and even death. Among people 75 and older, falls are far more likely to cause admissions into a long term care facility than for adults 10…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47999/psn-pdf
    May 15, 2019 - Pregnancy-related deaths: saving women’s lives before, during and after delivery. May 15, 2019 CDC Vital Signs. May 7, 2019. https://psnet.ahrq.gov/issue/pregnancy-related-deaths-saving-womens-lives-during-and-after-delivery Maternal morbidity and mortality is a worldwide patient safety problem. This analysis desc…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841773/psn-pdf
    December 21, 2022 - Inappropriate prescribing of opioids for patients undergoing surgery. December 21, 2022 Varady NH, Worsham CM, Chen AF, et al. Inappropriate prescribing of opioids for patients undergoing surgery. Proc Natl Acad Sci USA. 2022;119(49):e2210226119. doi:10.1073/pnas.2210226119. https://psnet.ahrq.gov/issue/inappropri…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39207/psn-pdf
    May 24, 2015 - An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study. May 24, 2015 Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009. https://psnet.ahrq.gov/issue/depth-investigation-causes-prescribing-errors-foundation…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34912/psn-pdf
    February 03, 2010 - Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. February 3, 2010 Rosenstein AH, O'Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. Am J Nurs. 2005;105(1):54-64; quiz 64-5. https://psnet.ahrq.gov/issue/disruptive-behavior-and-clinical-outcom…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41625/psn-pdf
    December 02, 2014 - Effects of CPOE on provider cognitive workload: a randomized crossover trial. December 2, 2014 Avansino J, Leu MG. Effects of CPOE on provider cognitive workload: a randomized crossover trial. Pediatrics. 2012;130(3):e547-52. doi:10.1542/peds.2011-3408. https://psnet.ahrq.gov/issue/effects-cpoe-provider-cognitive-…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36532/psn-pdf
    March 28, 2011 - A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability. March 28, 2011 Lingard LA, Regehr G, Espin S, et al. A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39085/psn-pdf
    November 11, 2009 - Integrating ethics and patient safety: the role of clinical ethics consultants in quality improvement. November 11, 2009 Opel DJ, Brownstein D, Diekema DS, et al. Integrating ethics and patient safety: the role of clinical ethics consultants in quality improvement. J Clin Ethics. 2009;20(3):220-6. https://psnet.ah…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40447/psn-pdf
    March 04, 2015 - Analysis and prioritization of near-miss adverse events in a radiology department. March 4, 2015 Thornton RH, Miransky J, Killen A, et al. Analysis and prioritization of near-miss adverse events in a radiology department. AJR Am J Roentgenol. 2011;196(5):1120-4. doi:10.2214/AJR.10.5373. https://psnet.ahrq.gov/issu…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42387/psn-pdf
    December 30, 2014 - 'Bad apples': time to redefine as a type of systems problem? December 30, 2014 Shojania KG, Dixon-Woods M. 'Bad apples': time to redefine as a type of systems problem? BMJ Qual Saf. 2013;22(7):528-531. doi:10.1136/bmjqs-2013-002138. https://psnet.ahrq.gov/issue/bad-apples-time-redefine-type-systems-problem While …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45587/psn-pdf
    January 23, 2017 - Comparison of physician and computer diagnostic accuracy. January 23, 2017 Semigran HL, Levine DM, Nundy S, et al. Comparison of Physician and Computer Diagnostic Accuracy. JAMA Intern Med. 2016;176(12):1860-1861. doi:10.1001/jamainternmed.2016.6001. https://psnet.ahrq.gov/issue/comparison-physician-and-computer-d…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837001/psn-pdf
    April 27, 2022 - Final Report of the Ockenden Review. April 27, 2022 London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294. https://psnet.ahrq.gov/issue/final-report-ockenden-review Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves as the final conclusions of an i…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47765/psn-pdf
    February 20, 2019 - Negative behaviours in health care: prevalence and strategies. February 20, 2019 Layne DM, Nemeth LS, Mueller M, et al. Negative behaviours in health care: Prevalence and strategies. J Nurs Manag. 2019;27(1):154-160. doi:10.1111/jonm.12660. https://psnet.ahrq.gov/issue/negative-behaviours-health-care-prevalence-an…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45427/psn-pdf
    October 19, 2016 - How to monitor patient safety in primary care? Healthcare professionals' views. October 19, 2016 Samra R, Car J, Majeed A, et al. How to monitor patient safety in primary care? Healthcare professionals' views. JRSM Open. 2016;7(8):2054270416648045. doi:10.1177/2054270416648045. https://psnet.ahrq.gov/issue/how-mon…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836832/psn-pdf
    March 30, 2022 - Improving Education—A Key to Better Diagnostic Outcomes. March 30, 2022 Olson APJ, Danielson J, Stanley J, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2022. AHRQ Publication No. 22-0026-1-EF https://psnet.ahrq.gov/issue/improving-education-key-better-diagnostic-outcomes Diagnostic skil…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47321/psn-pdf
    June 19, 2019 - Validation of a mobile app for reducing errors of administration of medications in an emergency. June 19, 2019 Baumann D, Dibbern N, Sehner S, et al. Validation of a mobile app for reducing errors of administration of medications in an emergency. J Clin Monit Comput. . 2019;33(3):531-539. doi:10.1007/s10877-018-018…
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