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psnet.ahrq.gov/issue/whom-bell-commission-tolls-unintended-effects-limiting-residents-hours
April 20, 2011 - Commentary
For whom the Bell Commission tolls: unintended effects of limiting residents' hours.
Citation Text:
Millard WB. For whom the bell commission tolls: unintended effects of limiting residents' hours. Ann Emerg Med. 2009;54(4):A25-9.
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psnet.ahrq.gov/issue/impact-and-implications-disruptive-behavior-perioperative-arena
February 03, 2010 - Study
Impact and implications of disruptive behavior in the perioperative arena.
Citation Text:
Rosenstein AH, O'Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006;203(1):96-105.
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psnet.ahrq.gov/issue/action-research-simulation-team-communication-and-bringing-tacit-voice-society-simulation
April 16, 2019 - Study
Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare.
Citation Text:
Forsythe L. Action research, simulation, team communication, and bringing the tacit into voice society for simulation in healthcare. Simul Heal…
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www.ahrq.gov/news/newsroom/case-studies/ktcquips92.html
October 01, 2014 - Maryland Hospitals Revise Medication Reconciliation Process With AHRQ Toolkit
Search All Impact Case Studies
April 2012
After participating in AHRQ-sponsored learning sessions and provider support calls, Delmarva Foundation for Medical Care, the Maryland Quality Improvement Organization (QIO), worked with h…
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psnet.ahrq.gov/issue/health-outcomes-associated-potentially-inappropriate-medication-use-older-adults
June 29, 2011 - Study
Health outcomes associated with potentially inappropriate medication use in older adults.
Citation Text:
Fick DM, Mion LC, Beers MH, et al. Health outcomes associated with potentially inappropriate medication use in older adults. Res Nurs Health. 2008;31(1):42-51. doi:10.1002/nur…
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psnet.ahrq.gov/issue/educational-intervention-increase-speaking-behaviors-nurses-and-improve-patient-safety
May 08, 2013 - Study
An educational intervention to increase "speaking-up" behaviors in nurses and improve patient safety.
Citation Text:
Sayre MM, McNeese-Smith D, Leach LS, et al. An educational intervention to increase "speaking-up" behaviors in nurses and improve patient safety. J Nurs Care Qual.…
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psnet.ahrq.gov/issue/review-verbal-order-policies-acute-care-hospitals
January 03, 2017 - Study
A review of verbal order policies in acute care hospitals.
Citation Text:
Wakefield DS, Wakefield BJ, Despins L, et al. A review of verbal order policies in acute care hospitals. Jt Comm J Qual Patient Saf. 2012;38(1):24-33.
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psnet.ahrq.gov/issue/towards-understanding-information-dynamics-handover-process-aged-care-settings-prerequisite
August 19, 2016 - Study
Towards an understanding of the information dynamics of the handover process in aged care settings—a prerequisite for the safe and effective use of ICT.
Citation Text:
Lyhne S, Georgiou A, Marks A, et al. Towards an understanding of the information dynamics of the handover proces…
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psnet.ahrq.gov/issue/leveraging-trainees-improve-quality-and-safety-point-care-three-models-engagement
September 20, 2017 - Commentary
Leveraging trainees to improve quality and safety at the point of care: three models for engagement.
Citation Text:
Faherty LJ, Mate KS, Moses JM. Leveraging Trainees to Improve Quality and Safety at the Point of Care: Three Models for Engagement. Acad Med. 2016;91(4):503-9. d…
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psnet.ahrq.gov/issue/socio-technical-systems-approach-studying-interruptions-understanding-interrupters
October 03, 2013 - Study
A socio-technical systems approach to studying interruptions: understanding the interrupter's perspective.
Citation Text:
Rivera J. A socio-technical systems approach to studying interruptions: understanding the interrupter's perspective. Appl Ergon. 2014;45(3):747-56. doi:10.1016/…
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www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/resources/qapi-leadership-rounding-guide-centers-for-medicare.pdf
June 02, 2025 - QAPI Leadership Rounding Guide
Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.
Directions: Leadership rounding is a process where leaders (e.g., administrator, department heads, and nurse
managers) are out in the building with staff and residents, t…
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psnet.ahrq.gov/issue/global-patient-outcomes-after-elective-surgery-prospective-cohort-study-27-low-middle-and
January 23, 2019 - Study
Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.
Citation Text:
group ISOS. Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries. Br J Anaesth. 2…
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psnet.ahrq.gov/issue/effect-fit-between-organizational-culture-and-structure-medication-errors-medical-group
June 30, 2009 - Study
The effect of the fit between organizational culture and structure on medication errors in medical group practices.
Citation Text:
Kaissi A, Kralewski J, Dowd B, et al. The effect of the fit between organizational culture and structure on medication errors in medical group practi…
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psnet.ahrq.gov/issue/observational-study-postoperative-handoff-standardization-failures
March 10, 2021 - Study
An observational study of postoperative handoff standardization failures.
Citation Text:
Abraham J, Meng A, Sona C, et al. An observational study of postoperative handoff standardization failures. Int J Med Inform. 2021;151:104458. doi:10.1016/j.ijmedinf.2021.104458.
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digital.ahrq.gov/program-overview/research-stories/use-ehr-embedded-tools-improve-screening-intimate-partner
January 01, 2023 - Use of EHR-Embedded Tools to Improve Screening for Intimate Partner Violence
Theme:
Optimizing Care Delivery for Clinicians
Subtheme:
Leveraging Technology for Personalized, Evidence-Based Care and Decision Support
An intervention with new tools and formalized procedures to screen for int…
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psnet.ahrq.gov/issue/anybody-list-youre-more-worried-about-qualitative-analysis-exploring-functions-questions
January 22, 2016 - Study
"Anybody on this list that you're more worried about?" Qualitative analysis exploring the functions of questions during end of shift handoffs.
Citation Text:
O'Brien CM, Flanagan ME, Bergman AA, et al. "Anybody on this list that you're more worried about?" Qualitative analysis expl…
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psnet.ahrq.gov/issue/resident-physicians-advice-seeking-and-error-making-social-networks-approach
July 13, 2010 - Study
Resident physicians' advice seeking and error making: a social networks approach.
Citation Text:
Katz-Navon T, Naveh E. Resident physicians' advice seeking and error making: a social networks approach. Health Care Manage Rev. 2022;47(3):e41-e49. doi:10.1097/hmr.0000000000000333.
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psnet.ahrq.gov/issue/infection-prevention-long-term-care-re-evaluating-system-using-human-factors-engineering
August 21, 2024 - Commentary
Infection prevention in long-term care: re-evaluating the system using a human factors engineering approach.
Citation Text:
Katz MJ, Gurses AP. Infection prevention in long-term care: re-evaluating the system using a human factors engineering approach. Infect Control Hosp Epid…
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psnet.ahrq.gov/issue/dna-damage-response-and-patient-safety-engaging-our-molecular-biology-oriented-colleagues
March 11, 2020 - Commentary
The DNA damage response and patient safety: engaging our molecular biology-oriented colleagues.
Citation Text:
Pukk K, Aron DC. The DNA damage response and patient safety: engaging our molecular biology-oriented colleagues. International Journal for Quality in Health Care. 2…
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digital.ahrq.gov/2019-year-review/research-summary/health-information-exchange-streamlines-communication-between
January 01, 2019 - Health Information Exchange Streamlines Communication Between Poison Control Centers and Emergency Departments
The research team created the first HIE capability between a poison control center (PCC) and ED to reduce errors, improve decision making, and improve continuity of care for poisonings, including drug ove…