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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45225/psn-pdf
    June 15, 2016 - A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. June 15, 2016 Clifford SP, Mick PB, Derhake BM. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. J Investig Med High Impact Case R…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848316/psn-pdf
    May 03, 2023 - Floating to intensive care units: nurses' messages for instant action to promote patient safety. May 3, 2023 Ahmed FR, Timmins F, Dias JM, et al. Floating to intensive care units: nurses' messages for instant action to promote patient safety. Nurs Crit Care. 2023;28(6):902-912. doi:10.1111/nicc.12907. https://psne…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45535/psn-pdf
    January 23, 2017 - Surgical specimen management: a descriptive study of 648 adverse events and near misses. January 23, 2017 Steelman VM, Williams TL, Szekendi MK, et al. Surgical specimen management: a descriptive study of 648 adverse events and near misses. Arch Pathol Lab Med. 2016;140(12):1390-1396. https://psnet.ahrq.gov/issue/…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38142/psn-pdf
    April 30, 2014 - Medical error disclosure among pediatricians: choosing carefully what we might say to parents. April 30, 2014 Loren DJ, Klein EJ, Garbutt J, et al. Medical Error Disclosure Among Pediatricians. Arch Pediatr Adolesc Med. 2008;162(10):922-927. doi:10.1001/archpedi.162.10.922. https://psnet.ahrq.gov/issue/medical-err…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41497/psn-pdf
    April 05, 2013 - Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. April 5, 2013 Payne CE, Stein JM, Leong T, et al. Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods. BMJ Qual Saf. 2012;21(11):925-32. doi:1…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867089/psn-pdf
    November 06, 2024 - Focused team engagements to enhance interprofessional collaboration and safety behaviors among novice nurses and medical residents. November 6, 2024 Manuel R, Barber A, Kern J, et al. Focused team engagements to enhance interprofessional collaboration and safety behaviors among novice nurses and medical residents.…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/858163/psn-pdf
    December 13, 2023 - Blackbox error management: how do practices deal with critical incidents in everyday practice? A qualitative interview study. December 13, 2023 Bodek A, Pommée M, Berger A, et al. Blackbox error management: how do practices deal with critical incidents in everyday practice? A qualitative interview study. BMC Prim …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37803/psn-pdf
    January 06, 2017 - Paying the piper: investing in infrastructure for patient safety.  January 6, 2017 Pronovost P, Rosenstein BJ, Paine LA, et al. Paying the piper: investing in infrastructure for patient safety. Jt Comm J Qual Patient Saf. 2008;34(6):342-8. https://psnet.ahrq.gov/issue/paying-piper-investing-infrastructure-patient-…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37227/psn-pdf
    December 15, 2011 - Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study. December 15, 2011 Sinopoli DJ, Needham DM, Thompson DA, et al. Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study. J Crit Care. 2007;22(3):177-83. http…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43895/psn-pdf
    November 03, 2015 - The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age. November 3, 2015 Wachter R. New York, NY: McGraw-Hill; 2015. ISBN: 9780071849463. https://psnet.ahrq.gov/issue/digital-doctor-hope-hype-and-harm-dawn-medicines-computer-age Over the past few years, driven by $30 billion of federal inc…

  11. Supplier, Inputs, Process, Outputs, Customer | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/sipoc
    January 01, 2023 - Supplier, Inputs, Process, Outputs, Customer Acronym SIPOC Description A supplier, inputs, process, outputs, customer (SIPOC) diagram is a high-level flowchart that includes data on suppliers, inputs, outputs, and users involved in a process. Uses To identify important components …

  12. Use Case | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/use-case
    January 01, 2023 - Use Case Description A use case is a set of instructions that an individual in a process completes to go through one single step in that process. It describes what the user does to interact with a system. Uses To understand how a user is aided by a system when completing a specific task. …

  13. Requirements Table | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/requirements-table
    January 01, 2023 - Requirements Table Description The requirements table is a tool for identifying customers and customer requirements. The format separates users into four categories and requirements into two categories, allowing for a more complete list of customers and their requirements. Uses When creating…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39495/psn-pdf
    September 20, 2011 - Safe Practices for Better Healthcare: 2010 Update. September 20, 2011 Washington, DC: National Quality Forum; 2010. https://psnet.ahrq.gov/issue/safe-practices-better-healthcare-2010-update The National Quality Forum originally published the Safe Practices for Better Healthcare in 2003. These practices are intende…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44965/psn-pdf
    February 15, 2017 - Identification and Prioritization of Health IT Patient Safety Measures. February 15, 2017 Washington, DC: National Quality Forum; February 2016. https://psnet.ahrq.gov/issue/identification-and-prioritization-health-it-patient-safety-measures Health information technology (IT) has transformed health care and improv…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865522/psn-pdf
    April 10, 2024 - An analysis of incident reports related to electronic medication management: how they change over time. April 10, 2024 Kinlay M, Zheng WY, Burke R, et al. An analysis of incident reports related to electronic medication management: how they change over time. J Patient Saf. 2024;20(3):202-208. doi:10.1097/pts.00000…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73214/psn-pdf
    May 05, 2021 - Patient and physician perspectives of deprescribing potentially inappropriate medications in older adults with a history of falls: a qualitative study. May 5, 2021 Hahn EE, Munoz-Plaza CE, Lee EA, et al. Patient and physician perspectives of deprescribing potentially inappropriate medications in older adults with …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36089/psn-pdf
    March 03, 2011 - The impact of the 80-hour resident workweek on surgical residents and attending surgeons. March 3, 2011 Hutter MM, Kellogg KC, Ferguson CM, et al. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg. 2006;243(6):864-71; discussion 871-5. https://psnet.ahrq.gov/issue/i…

  19. View PDF (pdf file)

    integrationacademy.ahrq.gov/print/pdf/node/23262
    View PDF Behavioral Health Integration Collaborative View PDF Website https://www.ama-assn.org/delivering-care/public-health/behavioral-health-integration-bhi-collaborative Mission To catalyze effective and sustainable integration of behavioral and mental health care into physician practices. Contact: AMA Media &…

  20. Vermont | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/past-initiatives/privacy-and-security-project/vermont
    January 01, 2023 - Vermont Team Description The State of Vermont has been working toward a vision consistent with a nationwide health information network since 2004.  Vermont expects to have in place the infrastructure and agreements to implement an electronic health records (EHR) network across the state wi…
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