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psnet.ahrq.gov/issue/fate-pediatric-prescriptions-community-pharmacies
September 27, 2016 - Study
The fate of pediatric prescriptions in community pharmacies.
Citation Text:
Condren ME, Desselle SP. The fate of pediatric prescriptions in community pharmacies. J Patient Saf. 2015;11(2):79-88. doi:10.1097/PTS.0b013e3182948a7d.
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psnet.ahrq.gov/issue/or-and-just-culture
February 01, 2017 - Commentary
The OR and a "just culture."
Citation Text:
Hamlin L. The OR and a "just culture". AORN J. 2009;90(4):495-498. doi:10.1016/j.aorn.2009.09.003.
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psnet.ahrq.gov/issue/pre-surgery-briefings-and-safety-climate-operating-theatre
September 27, 2016 - Study
Pre-surgery briefings and safety climate in the operating theatre.
Citation Text:
Allard J, Bleakley A, Hobbs A, et al. Pre-surgery briefings and safety climate in the operating theatre. BMJ Qual Saf. 2011;20(8):711-7. doi:10.1136/bmjqs.2009.032672.
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psnet.ahrq.gov/issue/dental-patient-safety-military-health-system-joining-medicine-journey-high-reliability
October 19, 2022 - Study
Dental patient safety in the military health system: joining medicine in the journey to high reliability.
Citation Text:
Stahl JM, Mack K, Cebula S, et al. Dental Patient Safety in the Military Health System: Joining Medicine in the Journey to High Reliability. Mil Med. 2019. doi:1…
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psnet.ahrq.gov/issue/why-do-gdps-fail-recognise-oral-cancer-argument-oral-cancer-checklist
March 13, 2024 - Commentary
Why do GDPs fail to recognise oral cancer? The argument for an oral cancer checklist.
Citation Text:
Dave B. Why do GDPs fail to recognise oral cancer? The argument for an oral cancer checklist. Br Dent J. 2013;214(5):223-5. doi:10.1038/sj.bdj.2013.214.
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psnet.ahrq.gov/issue/delirium-hospitalized-older-adults
December 15, 2008 - Commentary
Delirium in hospitalized older adults.
Citation Text:
Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017;377(15):1456-1466. doi:10.1056/NEJMcp1605501.
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psnet.ahrq.gov/issue/unintended-harm-associated-hospital-readmissions-reduction-program
August 20, 2018 - Commentary
Unintended harm associated with the Hospital Readmissions Reduction Program.
Citation Text:
Fonarow GC. Unintended Harm Associated With the Hospital Readmissions Reduction Program. JAMA. 2018;320(24):2539-2541. doi:10.1001/jama.2018.19325.
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psnet.ahrq.gov/issue/standardized-sign-out-reduces-intern-perception-medical-errors-general-internal-medicine-ward
August 04, 2021 - Study
Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward.
Citation Text:
Salerno SM, Arnett M, Domanski JP. Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward. Teach Learn Med. 200…
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psnet.ahrq.gov/issue/team-types-perceived-efficiency-and-team-climate-swedish-cross-professional-teamwork
October 18, 2023 - Study
Team types, perceived efficiency and team climate in Swedish cross-professional teamwork.
Citation Text:
Thylefors I, Persson O, Hellström D. Team types, perceived efficiency and team climate in Swedish cross-professional teamwork. J Interprof Care. 2005;19(2):102-14.
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psnet.ahrq.gov/issue/evaluating-physician-performance-individualizing-care-pilot-study-tracking-contextual-errors
September 20, 2011 - Study
Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making.
Citation Text:
Weiner SJ, Schwartz A, Yudkowsky R, et al. Evaluating physician performance at individualizing care: a pilot study tracking contextual err…
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psnet.ahrq.gov/issue/medication-reconciliation-emergency-department-opportunities-workflow-redesign
August 04, 2021 - Commentary
Medication reconciliation in the emergency department: opportunities for workflow redesign.
Citation Text:
Hummel J, Evans PC, Lee H. Medication reconciliation in the emergency department: opportunities for workflow redesign. Qual Saf Health Care. 2010;19(6):531-5. doi:10.11…
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psnet.ahrq.gov/issue/medical-reconciliation-patients-discharged-emergency-department
March 04, 2015 - Study
Medical reconciliation in patients discharged from the emergency department.
Citation Text:
Sharma AN, Dvorkin R, Tucker V, et al. Medical reconciliation in patients discharged from the emergency department. J Emerg Med. 2012;43(2):366-73. doi:10.1016/j.jemermed.2011.05.080.
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psnet.ahrq.gov/issue/geometric-probability-distribution-modeling-error-risk-during-prescription-dispensing
December 24, 2008 - Study
Geometric probability distribution for modeling of error risk during prescription dispensing.
Citation Text:
Carnahan BJ, Maghsoodloo S, Flynn EA, et al. Geometric probability distribution for modeling of error risk during prescription dispensing. Am J Health Syst Pharm. 2006;63(…
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psnet.ahrq.gov/issue/strategies-increase-reporting-near-misses-and-adverse-events
September 30, 2012 - Commentary
Strategies to increase reporting of near misses and adverse events.
Citation Text:
Conerly C. Strategies to increase reporting of near misses and adverse events. J Nurs Care Qual. 2007;22(2):102-6.
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www.ahrq.gov/es/programs/index.html?page=2
Digital Healthcare Research Advancing healthcare quality, safety, and effectiveness through the evolving digital healthcare ecosystem. More
PSNet Discover the latest literature, news, and expert commentary on patient safety topics. More
CAHPS The CAHPS program aims to advance our scientific …
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www.ahrq.gov/takeheart/training/module-1/index.html
December 01, 2022 - Module 1: Welcome to the TAKEheart Initiative and the Benefits of Increasing Cardiac Rehabilitation
YouTube embedded video: https://www.youtube-nocookie.com/embed/aSNL1eVhBak
Video: Welcome to the TAKEheart Initiative and the Benefits of Increasing Cardiac Rehabilitation Module 1 (1:09:26)
Slides: W…
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psnet.ahrq.gov/issue/patient-safety-trauma-maximal-impact-management-errors-level-i-trauma-center
February 19, 2020 - Study
Patient safety in trauma: maximal impact management errors at a level I trauma center.
Citation Text:
Ivatury RR, Guilford K, Malhotra AK, et al. Patient safety in trauma: maximal impact management errors at a level I trauma center. J Trauma. 2008;64(2):265-270; discussion 270-27…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.pdf
January 01, 2010 - Strategy 4: IDEA Discharge Planning (Tool 3)
Guide to Patient and Family Engagement :: 1
Improving Discharge Outcomes with Patients and Families
Evidence for engaging patients
and families in discharge planning
Nearly 20 percent of patients experience an adverse
event within 30 days of discharge.1,2 Re…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/sustainability-tool.docx
May 01, 2017 - AHRQ Safety Program for Ambulatory Surgery
Module 4: Sustainability
Sustainability Tool
Background: This tool can be used to identify sustainability issues in planning and implementing your improvement efforts.
How to use this tool: The Implementation Team leader (or individual designated by the leader) should comple…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/131-what-are-the-4-es-one-pager.docx
May 24, 2024 - The aim is to Engage hearts and minds and thus, change attitudes and behaviors.1-6
Raise awareness of the problem, communicate benefits of the solution, and lay out the goals for the intervention.
· Use unit data, published literature, and national benchmarks. Storytelling is an underrated tool.
Engagement is not a on…