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psnet.ahrq.gov/node/60885/psn-pdf
September 02, 2020 - Becoming a High Reliability Organization.
September 2, 2020
VHA Forum. Summer 2020;1-12.
https://psnet.ahrq.gov/issue/becoming-high-reliability-organization
High reliability attainment is a stated goal for health care organizations. This special issue covers
established initiatives at the United States Veterans He…
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psnet.ahrq.gov/node/35254/psn-pdf
April 06, 2011 - Adverse events and near miss reporting in the NHS.
April 6, 2011
Shaw R. Adverse events and near miss reporting in the NHS. Quality and Safety in Health Care.
2005;14(4). doi:10.1136/qshc.2004.010553.
https://psnet.ahrq.gov/issue/adverse-events-and-near-miss-reporting-nhs
This study evaluated the utility of a volu…
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psnet.ahrq.gov/node/36488/psn-pdf
January 07, 2011 - Horus meets Nightingale in the modern age: how nursing
communicates with pharmacy in HCIT era.
January 7, 2011
Armstrong I, Cox MA. Horus meets Nightingale in the modern age: How nursing communicates with
pharmacy in HCIT era. Stud Health Technol Inform. 2006;122:585-6.
https://psnet.ahrq.gov/issue/horus-meets-nig…
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psnet.ahrq.gov/node/38812/psn-pdf
April 12, 2011 - Management of test results in family medicine offices.
April 12, 2011
Elder NC, McEwen TR, Flach JM, et al. Management of test results in family medicine offices. Ann Fam
Med. 2009;7(4):343-51. doi:10.1370/afm.961.
https://psnet.ahrq.gov/issue/management-test-results-family-medicine-offices
This study evaluated co…
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psnet.ahrq.gov/node/60260/psn-pdf
April 22, 2020 - Joint Statement on Multiple Patients Per Ventilator.
April 22, 2020
The Anesthesia Patient Safety Foundation, Society of Critical Care Medicine, American Association for
Respiratory Care, American Society of Anesthesiologists, American Association of Critical?Care Nurses,
and American College of Chest Physicians. M…
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psnet.ahrq.gov/node/42768/psn-pdf
November 27, 2013 - Findings and Lessons From the Improving Management
of Individuals With Complex Health Care Needs Through
Health IT Grant Initiative.
November 27, 2013
Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-
0058-EF.
https://psnet.ahrq.gov/issue/findings-and-lesso…
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psnet.ahrq.gov/node/35660/psn-pdf
June 25, 2010 - Increased catheter-related bloodstream infection rates
after the introduction of a new mechanical valve
intravenous access port.
June 25, 2010
Maragakis LL, Bradley KL, Song X, et al. Increased catheter-related bloodstream infection rates after the
introduction of a new mechanical valve intravenous access port. In…
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psnet.ahrq.gov/node/39089/psn-pdf
November 11, 2009 - Blame culture and defensive medicine.
November 11, 2009
Catino M. Blame culture and defensive medicine. Cognition, Technology & Work. 2009;11(4).
doi:10.1007/s10111-009-0130-y.
https://psnet.ahrq.gov/issue/blame-culture-and-defensive-medicine
This study surveyed more than 300 Italian general practitioners and foun…
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psnet.ahrq.gov/node/35564/psn-pdf
June 17, 2014 - Medication safety issue brief. Small and rural
hospitals—unique challenges, unique solutions.
June 17, 2014
Association AH, Pharmacists AS of H-S, Networks H & H. Medication Safety Issue Brief. Small and rural
hospitals--unique challenges, unique solutions. Hospitals & health networks. 2005;79(11):45-6.
https://ps…
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digital.ahrq.gov/ahrq-funded-projects/improving-pediatric-cancer-survivorship-care-through-survivorlink/final-report
January 01, 2023 - Improving Pediatric Cancer Survivorship Care Through SurvivorLink - Final Report
Citation
Mertens A. Improving Pediatric Cancer Survivorship Care Through SurvivorLink - Final Report. (Prepared by Emory University under Grant No. R18 HS017831). Rockville, MD: Agency for Healthcare Research and Quality,…
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digital.ahrq.gov/ahrq-funded-projects/electronic-personal-health-record-mental-health-consumers/final-report
January 01, 2023 - An Electronic Personal Health Record for Mental Health Consumers - Final Report
Citation
Druss B. An Electronic Personal Health Record for Mental Health Consumers - Final Report. (Prepared by Emory University under Grant No. R18 HS017829). Rockville, MD: Agency for Healthcare Research and Quality, 201…
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digital.ahrq.gov/ahrq-funded-projects/web-based-renal-transplant-patient-medication-system/final-report
January 01, 2023 - Web-based Renal Transplant Patient Medication System - Final Report
Citation
Friedman A. Web-based Renal Transplant Patient Medication System - Final Report. (Prepared by Yale University under Grant No. R01 HS015038). Rockville, MD: Agency for Healthcare Research and Quality, 2007.
PDF
W…
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digital.ahrq.gov/ahrq-funded-projects/context-aware-knowledge-delivery-electronic-health-records/citation/multi
January 01, 2023 - Multi-national, multi-institutional analysis of clinical decision support data needs to inform development of the HL7 Virtual Medical Record Standard.
Citation
Kawamoto K, Del Fiol G, Strasberg HR, et al. Multi-national, multi-institutional analysis of clinical decision support data needs to inform de…
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digital.ahrq.gov/ahrq-funded-projects/anesthesiology-control-tower-feedback-alerts-supplement-treatment-actfast/citation/study
January 01, 2023 - Study protocol for the Anesthesiology Control Tower-Feedback Alerts to Supplement Treatments (ACTFAST-3) trial: a pilot randomized controlled trial in intraoperative telemedicine.
Citation
Gregory S, Murray-Torres TM, Fritz BA, Ben Abdallah A, Helsten DL, Wildes TS, Sharma A, Avidan MS; ACTFAST Study …
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digital.ahrq.gov/ahrq-funded-projects/trial-decision-support-improve-diabetes-outcomes/citation/care-fragmentation
January 01, 2023 - Care fragmentation and emergency department use among complex patients with diabetes.
Citation
Liu CW, Einstadter D, Cebul RD. Care fragmentation and emergency department use among complex patients with diabetes. Am J Manag Care 2010 Jun;16(6):413-20.
Link
Liu CW, Einstadter D, Cebul RD. Care…
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digital.ahrq.gov/ahrq-funded-projects/trial-decision-support-improve-diabetes-outcomes/citation/electronic-medical
January 01, 2023 - Electronic medical record-assisted design of a cluster-randomized trial to improve diabetes care and outcomes.
Citation
Love TE, Cebul RD, Einstadter D, et al. Electronic medical record-assisted design of a cluster-randomized trial to improve diabetes care and outcomes. J Gen Intern Med 2008 Apr;23(4)…
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digital.ahrq.gov/ahrq-funded-projects/best-practices-integrating-clinical-decision-support-clinical-workflow/final-report
January 01, 2023 - Best Practices For Integrating Clinical Decision Support Into Clinical Workflow - Final Report
Citation
Jean-Jacques, M. Best Practices For Integrating Clinical Decision Support Into Clinical Workflow - Final Report. (Prepared by Northwestern University under Grant No. R18 HS022767). Rockville, MD: Ag…
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psnet.ahrq.gov/node/43948/psn-pdf
May 20, 2015 - Human factors engineering: its place and potential in OR
safety.
May 20, 2015
Criscitelli T. Human factors engineering: its place and potential in OR safety. AORN J. 2015;101(5):571-3.
doi:10.1016/j.aorn.2015.02.013.
https://psnet.ahrq.gov/issue/human-factors-engineering-its-place-and-potential-or-safety
Human fa…
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digital.ahrq.gov/principal-investigator/sim-ida
January 01, 2023 - Sim, Ida
Standardized integration of person-generated data into routine clinical care.
Citation
Zeng B, Bove R, Carini S, Lee JS, Pollak JP, Schleimer E, Sim I. Standardized integration of person-generated data into routine clinical care. JMIR Mhealth Uhealth. 2022 Feb 10;10(…
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digital.ahrq.gov/ahrq-funded-projects/patient-centered-outcomes-research-clinical-decision-support-cds-connect/year8-final-report
January 08, 2025 - CDS Connect- Year 8 Final Report
Citation
Final Report (Year 8 of CDS Connect) CDS Connect Maintenance and Update Prepared under Contract No. 75FCMC18D0047. AHRQ Publication No. 24-0067. Rockville, MD: Agency for Healthcare Research and Quality; August 2024.
PDF
cds-connect-year-8-final-…