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psnet.ahrq.gov/issue/systems-approach-and-systems-engineering-applied-health-care-improving-patient-safety-and
August 12, 2020 - Commentary
Systems approach and systems engineering applied to health care: improving patient safety and health care delivery.
Citation Text:
Systems approach and systems engineering applied to health care: improving patient safety and health care delivery. Ravitz AD, Sapirstein A, Pha…
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psnet.ahrq.gov/issue/surgeon-reported-conflict-intensivists-about-postoperative-goals-care
September 26, 2012 - Study
Surgeon-reported conflict with intensivists about postoperative goals of care.
Citation Text:
Olson TJP, Brasel KJ, Redmann AJ, et al. Surgeon-reported conflict with intensivists about postoperative goals of care. JAMA Surg. 2013;148(1):29-35. doi:10.1001/jamasurgery.2013.403.
Co…
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psnet.ahrq.gov/issue/impact-health-system-membership-patient-safety-initiatives
October 12, 2011 - Study
The impact of health system membership on patient safety initiatives.
Citation Text:
Ford EW, Short JC. The impact of health system membership on patient safety initiatives. Health Care Manage Rev. 2012;33(1):13-20. doi:10.1097/01.hmr.0000304496.89684.7f.
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/cammisa-m-et-al-2004
January 01, 2004 - Cammisa M et al. 2004 "Design and implementation of an integrated HIS-RIS-PACS system: our experience."
Reference
Cammisa M, Guglielmi G, Zarrelli N, et al. Design and implementation of an integrated HIS-RIS-PACS system: our experience. Radiological Medicine 2004;107(1-2):102-112.
Abstract
"Pu…
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psnet.ahrq.gov/issue/interruption-handling-strategies-during-paediatric-medication-administration
July 27, 2018 - Study
Interruption handling strategies during paediatric medication administration.
Citation Text:
Colligan L, Bass EJ. Interruption handling strategies during paediatric medication administration. BMJ Qual Saf. 2012;21(11):912-7. doi:10.1136/bmjqs-2011-000292.
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psnet.ahrq.gov/issue/tamiflu-oseltamivir-oral-suspension-potential-medication-errors
November 07, 2012 - Government Resource
Tamiflu (oseltamivir) for oral suspension: potential medication errors.
Citation Text:
Tamiflu (oseltamivir) for oral suspension: potential medication errors. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 25, 2009.
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psnet.ahrq.gov/issue/review-current-and-emerging-approaches-address-failure-rescue
March 20, 2024 - Review
A review of current and emerging approaches to address failure-to-rescue.
Citation Text:
Taenzer AH, Pyke JB, McGrath SP. A review of current and emerging approaches to address failure-to-rescue. Anesthesiology. 2011;115(2):421-31. doi:10.1097/ALN.0b013e318219d633.
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psnet.ahrq.gov/issue/rounding-influence
February 22, 2010 - Newspaper/Magazine Article
Rounding to influence.
Citation Text:
Reinertsen JL, Johnson KM. Rounding to influence. Leadership method helps executives answer the "hows" in patient safety initiatives. Healthcare executive. 2010;25(5):72-5.
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psnet.ahrq.gov/issue/report-mid-staffordshire-nhs-foundation-trust-public-inquiry
November 06, 2015 - In 2010 the United Kingdom's Secretary of State for Health announced a full public inquiry into the Mid
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www.ahrq.gov/sites/default/files/2024-01/gandhi-report.pdf
January 01, 2024 - Final Progress Report: Using Barcode Technology to Improve Medication Safety
FINAL REPORT: April 16, 2007
Using Barcode Technology to Improve Medication Safety
Principal Investigator: Tejal Gandhi, tgandhi@partners.org
Brigham and Women’s Hospital
Tejal Gandhi MD, MPH, Principle Investigator
Eric Poon, MD, MPH, …
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effectivehealthcare.ahrq.gov/sites/default/files/07_diabetes_potential_high_impact_june_2012.pdf
January 01, 2012 - developed for
technologies and programs that appear to be close to diffusion into practice in the United … States. … States or that have just begun diffusing and that have completed an expert feedback loop. … States with life-threatening diabetes and no other treatment
options … States.
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effectivehealthcare.ahrq.gov/sites/default/files/celiac-disease_executive.pdf
January 01, 2016 - Although this report is limited to diagnostic methods
currently used in the United States, study location … States and Europe. … States. … These guidelines have not been adopted by
societies in the United States. … The prevalence
of celiac disease in the United States.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Banja.pdf
January 01, 2004 - Medicine’s 2000 report, To Err Is Human,1
marked a watershed in the patient safety movement in the United … States. … Section 8.12 of the AMA’s Code of Medical Ethics: Current
Opinions clearly states,
It is a fundamental … I end this article by describing how various States have enacted legislation
that has removed certain … A number of States have
passed legislation that makes certain representations suggesting or implying
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - In many states, you already have significant legal protections around data that you're sharing—at least … Now, that advantage is linked to a legal advantage because the states do differ a great deal in the level … There are many other states where the protection is less than fully adequate. … Most states, even if they do have peer review protection, provide it within institutional walls, and … health care incident reporting systems, including the Pennsylvania Patient Safety Authority and the United
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
April 22, 2004 - Chapanis states that human factors engineering “discovers and applies
information about human behavior … These strategies should be based on the
hierarchy of hazard control, which states that the best hazard
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psnet.ahrq.gov/web-mm/troubling-amine
September 01, 2003 - The Commentary Penicillamine and penicillin are listed as look-alike/sound-alike drugs by the United … States Pharmacopeia, along with approximately 1,100 other drug pairs.( 1 ) The literature describes
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Shoulder Dystocia
AHRQ Safety Program for Perinatal Care
Labor and Delivery Unit Safety
Shoulder Dystocia
Labor and Delivery Unit Safety—Shoulder Dystocia
Purpose of the tool: This tool describes the key perinatal safety elements related to the saf…
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digital.ahrq.gov/sites/default/files/docs/citation/health-equity-practical-guide.pdf
February 15, 2024 - document is made publicly available by AHRQ and may be
used and reprinted without permission in the United … Users outside the
United States must get permission from AHRQ to reprint or translate this product. … Utilization of preventive medical services in the United States: A comparison between
rural and urban … United States colorectal cancer screening practices
among American Indians/Alaska natives, blacks, and … United States Department of Commerce.
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meps.ahrq.gov/data_files/publications/st121/stat121.pdf
March 01, 2006 - in
obtaining more information about access, cost, use, financing, and quality of health care in the United … States.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_1-introduction-speaker-notes.pdf
July 01, 2023 - working toward elimination of all preventable maternal mortality and severe morbidity
across the United … States. … initiative based on
proven implementation approaches to improving maternal safety and outcomes in the
United … States.