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psnet.ahrq.gov/issue/achieving-perfect-handoff-patient-transfers-building-teamwork-and-trust
October 08, 2016 - Commentary
Achieving the 'perfect handoff' in patient transfers: building teamwork and trust.
Citation Text:
Clarke D, Werestiuk K, Schoffner A, et al. Achieving the 'perfect handoff' in patient transfers: building teamwork and trust. J Nurs Manag. 2012;20(5):592-8. doi:10.1111/j.1365-…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-sops-riverside-handoffs-webcast-bakdash.pdf
January 01, 2022 - Improving Hospital Handoffs Using AHRQ’s Surveys on Patient Safety Culture® Hospital Survey - Bakdash
AHRQ’s Surveys on Patient Safety Culture®
(SOPS®) Program
Jonathan Bakdash, Ph.D.
Center for Quality Improvement and Patient Safety, AHRQ
Agency for Healthcare Research and Quality
• AHRQ is:
► A research and …
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psnet.ahrq.gov/issue/year-1-medical-undergraduates-knowledge-and-attitudes-medical-error
March 24, 2011 - Study
Year 1 medical undergraduates' knowledge of and attitudes to medical error.
Citation Text:
Flin R, Patey R, Jackson J, et al. Year 1 medical undergraduates' knowledge of and attitudes to medical error. Med Educ. 2009;43(12):1147-55. doi:10.1111/j.1365-2923.2009.03499.x.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/putoolkit_module5_tools.docx
June 02, 2025 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 5 Tools
Action Plan Tool to Measure Pressure Ulcer Rates and Pressure Ulcer Prevention Practices
Tool 5C: Assessing Comprehensive Skin Assessment
Tool 5D: Assessing Standardized Risk Assessment
Tool 5E: Assessing Care Planning
AHRQ Pressure…
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psnet.ahrq.gov/issue/weaving-healthcare-tapestry-safety-and-communication
September 29, 2017 - Commentary
Weaving a healthcare tapestry of safety and communication.
Citation Text:
Hay J, Collin S, Koruth S. Weaving a healthcare tapestry of safety and communication. Nurs Manage. 2014;45(7):40-6. doi:10.1097/01.NUMA.0000451035.84587.7d.
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DOI Google…
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psnet.ahrq.gov/issue/chasing-6-sigma-drawing-lessons-cockpit-culture
April 22, 2015 - Commentary
Chasing the 6-sigma: drawing lessons from the cockpit culture.
Citation Text:
Hickey EJ, Halvorsen F, Laussen PC, et al. Chasing the 6-sigma: Drawing lessons from the cockpit culture. J Thorac Cardiovasc Surg. 2017;155(2). doi:10.1016/j.jtcvs.2017.09.097.
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psnet.ahrq.gov/issue/ensuring-staff-safety-when-treating-potentially-violent-patients
July 14, 2010 - Commentary
Ensuring staff safety when treating potentially violent patients.
Citation Text:
Roca RP, Charen B, Boronow J. Ensuring Staff Safety When Treating Potentially Violent Patients. JAMA. 2016;316(24):2669-2670. doi:10.1001/jama.2016.18260.
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DOI G…
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psnet.ahrq.gov/issue/my-brothers-keeper-must-physician-disclose-anothers-medical-error-and-potential-negligence
February 01, 2023 - Commentary
My brother's keeper: must a physician disclose another's medical error and potential negligence?
Citation Text:
Liang BA, Smith C by DS. My brother's keeper: must a physician disclose another's medical error and potential negligence? J Clin Anesth. 2007;19(7):558-562. doi:10…
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psnet.ahrq.gov/issue/viewpoint-patient-safety-primary-care-patients-are-not-just-beneficiary-critical-component
August 16, 2017 - Commentary
Viewpoint: Patient safety in primary care - patients are not just a beneficiary but a critical component in its achievement.
Citation Text:
Kavanagh KT, Cormier LE. Viewpoint: Patient safety in primary care – patients are not just a beneficiary but a critical component in its …
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psnet.ahrq.gov/issue/are-they-safe-there-patient-safety-and-trainees-practice
September 22, 2021 - Commentary
Are they safe in there? Patient safety and trainees in the practice.
Citation Text:
Byrnes PD, Crawford M, Wong B. Are they safe in there? - patient safety and trainees in the practice. Aust Fam Physician. 2012;41(1-2):26-9.
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/NCINQTobaccoUseHelp-References.pdf
August 01, 2012 - National Collaborative for Innovation in Quality Measurement
Tobacco Use and Help
List of References
Campaign for Tobacco-Free Kids. 2012. Tobacco Overview.
http://www.tobaccofreekids.org/facts_issues/tobacco_101/ (April 2012).
Campaign for Tobacco-Free Kids. 2011. Health Harms from Smoking and Other Tobac…
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psnet.ahrq.gov/issue/covid-19-nursing-homes-cms-needs-continue-strengthen-oversight-infection-prevention-and
October 26, 2022 - Book/Report
COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.
Citation Text:
COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control. Washington, DC: United States Government …
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psnet.ahrq.gov/issue/sbar-shared-mental-model-improving-communication-between-clinicians
January 02, 2017 - Study
SBAR: a shared mental model for improving communication between clinicians.
Citation Text:
Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32(3):167-75.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Tool_12_WkWthAdv_HO_508.docx
June 02, 2025 - Strategy 1: Working with Patients & Families as Advisors (Tool 12)
Strategy 1: Working With Patients & Families as Advisors (Tool 12)
Strategy 1: Working with Patients & Families as Advisors
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Strategy 1: Working With Patients & Families as Advisors (Tool 12)
Working With Patient an…
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psnet.ahrq.gov/issue/impact-checklists-inpatient-safety-outcomes-systematic-review-randomized-controlled-trials
September 29, 2021 - Review
The impact of checklists on inpatient safety outcomes: a systematic review of randomized controlled trials.
Citation Text:
Boyd J, Wu G, Stelfox HT. The Impact of Checklists on Inpatient Safety Outcomes: A Systematic Review of Randomized Controlled Trials. J Hosp Med. 2017;12(8):6…
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digital.ahrq.gov/type-care/tertiary-care
January 01, 2023 - Tertiary Care
ML-ROVER: Machine Learning to Reduce Laboratory Test Overutilization
Description
The study will develop, validate, implement, and assess the usability of a machine learning based clinical decision support tool designed to reduce laboratory testing overutilization…
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psnet.ahrq.gov/issue/utilizing-improvement-science-methods-improve-physician-compliance-proper-hand-hygiene
April 13, 2011 - Study
Utilizing improvement science methods to improve physician compliance with proper hand hygiene.
Citation Text:
White CM, Statile AM, Conway PH, et al. Utilizing improvement science methods to improve physician compliance with proper hand hygiene. Pediatrics. 2012;129(4):e1042-50.…
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psnet.ahrq.gov/issue/leadership-initiative-improve-communication-and-enhance-safety
March 11, 2009 - Commentary
A leadership initiative to improve communication and enhance safety.
Citation Text:
Donahue M, Miller M, Smith L, et al. A Leadership Initiative to Improve Communication and Enhance Safety. American Journal of Medical Quality. 2011;26(3). doi:10.1177/1062860610387410.
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psnet.ahrq.gov/issue/role-information-technology-healthcare-communications-efficiency-and-patient-safety
October 19, 2022 - Commentary
The role of information technology in healthcare communications, efficiency, and patient safety: application and results.
Citation Text:
Prince SB, Herrin DM. The role of information technology in healthcare communications, efficiency, and patient safety: application and res…
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psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improving-safety-iv-drug-administration
March 23, 2012 - Study
Use of failure mode and effects analysis in improving the safety of i.v. drug administration.
Citation Text:
Adachi W, Lodolce AE. Use of failure mode and effects analysis in improving the safety of i.v. drug administration. Am J Health Syst Pharm. 2005;62(9):917-20.
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