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psnet.ahrq.gov/issue/safety-home-care-use-internet-video-calls-double-check-interventions
August 04, 2021 - Study
Safety for home care: the use of internet video calls to double-check interventions.
Citation Text:
Bradford N, Armfield NR, Young J, et al. Safety for home care: the use of internet video calls to double-check interventions. J Telemed Telecare. 2012;18(8):434-437. doi:10.1258/jtt…
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psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance
November 18, 2020 - Commentary
Organizational learning: health care leaders need to design structures and processes that enhance collective learning.
Citation Text:
Bohmer RM, Edmondson AC. Organizational learning in health care. Health Forum J. 2001;44(2):32-35.
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psnet.ahrq.gov/issue/defining-critical-role-nurses-diagnostic-error-prevention-conceptual-framework-and-call
October 28, 2020 - Review
Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action.
Citation Text:
Gleason KT, Davidson PM, Tanner EK, et al. Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to act…
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psnet.ahrq.gov/issue/creating-learning-health-system-improving-diagnostic-safety-pragmatic-insights-us-health-care
May 12, 2021 - Study
Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care organizations.
Citation Text:
Giardina TD, Shahid U, Mushtaq U, et al. Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care…
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psnet.ahrq.gov/issue/veterans-health-administration-response-covid-19-crisis-surveillance-action
November 17, 2021 - Commentary
Veterans Health Administration response to the COVID-19 crisis: surveillance to action.
Citation Text:
Charles MA, Yackel EE, Mills PD, et al. Veterans Health Administration response to the COVID-19 crisis: surveillance to action. J Patient Saf. 2022;18(7):686-691. doi:10.1097…
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psnet.ahrq.gov/issue/omissions-care-nursing-homes-uniform-definition-research-and-quality-improvement
August 01, 2012 - Commentary
Omissions of care in nursing homes: a uniform definition for research and quality improvement.
Citation Text:
Mangrum R, Stewart MD, Gifford DR, et al. Omissions of care in nursing homes: a uniform definition for research and quality improvement. J Am Med Dir Assoc. 2020;21(11…
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psnet.ahrq.gov/issue/suicide-risk-changing-jobs-or-leaving-nursing-profession-aftermath-patient-safety-incident
July 22, 2020 - Study
Suicide risk, changing jobs, or leaving the nursing profession in the aftermath of a patient safety incident.
Citation Text:
Stovall M, Hansen L. Suicide risk, changing jobs, or leaving the nursing profession in the aftermath of a patient safety incident. Worldviews Evid Based Nurs…
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psnet.ahrq.gov/issue/barriers-incident-reporting-behavior-among-nursing-staff-study-based-theory-planned-behavior
February 27, 2019 - Study
Barriers to incident-reporting behavior among nursing staff: a study based on the theory of planned behavior.
Citation Text:
Lee Y-H, Yang C-C, Chen T-T. Barriers to incident-reporting behavior among nursing staff: A study based on the theory of planned behavior. J Manag Organ. 201…
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psnet.ahrq.gov/issue/temporal-clustering-critical-illness-events-medical-wards
January 31, 2024 - Study
Temporal clustering of critical illness events on medical wards.
Citation Text:
Doshi S, Shin S, Lapointe-Shaw L, et al. Temporal clustering of critical illness events on medical wards. JAMA Intern Med. 2023;183(9):924-932. doi:10.1001/jamainternmed.2023.2629.
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psnet.ahrq.gov/issue/development-and-evaluation-institute-healthcare-improvement-global-trigger-tool
February 10, 2015 - Commentary
Development and evaluation of the Institute for Healthcare Improvement global trigger tool.
Citation Text:
Classen DC, Lloyd RC, Provost LP, et al. Development and Evaluation of the Institute for Healthcare Improvement Global Trigger Tool. J Patient Saf. 2008;4(3). doi:10.10…
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psnet.ahrq.gov/issue/improving-patient-safety-handover-intensive-care-unit-general-ward-systematic-review
June 12, 2008 - Review
Improving patient safety in handover from intensive care unit to general ward: a systematic review.
Citation Text:
Wibrandt I, Lippert A. Improving Patient Safety in Handover From Intensive Care Unit to General Ward: A Systematic Review. J Patient Saf. 2020;16(3):199-210. doi:10.1…
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psnet.ahrq.gov/issue/reported-medication-events-paediatric-emergency-research-network-sharing-improve-patient
April 03, 2013 - Study
Reported medication events in a paediatric emergency research network: sharing to improve patient safety.
Citation Text:
Shaw KN, Lillis KA, Ruddy RM, et al. Reported medication events in a paediatric emergency research network: sharing to improve patient safety. Emerg Med J. 20…
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psnet.ahrq.gov/issue/encouraging-patients-speak-about-problems-cancer-care
March 11, 2013 - Study
Encouraging patients to speak up about problems in cancer care.
Citation Text:
Mazor KM, Kamineni A, Roblin DW, et al. Encouraging patients to speak up about problems in cancer care. J Patient Saf. 2021;17(8):e1278-e1284. doi:10.1097/pts.0000000000000510.
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psnet.ahrq.gov/issue/critical-incident-technique
January 07, 2015 - Study
Classic
The critical incident technique.
Citation Text:
FLANAGAN JC. The critical incident technique. Psychol Bull. 1954;51(4):327-358.
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psnet.ahrq.gov/issue/systematic-review-prevalence-and-types-adverse-events-interfacility-critical-care-transfers
November 25, 2020 - Review
A systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics.
Citation Text:
Alabdali A, Fisher JD, Trivedy C, et al. A Systematic Review of the Prevalence and Types of Adverse Events in Interfacility Critical Care Transf…
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integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan-integrating-behavioral-health-your-ambulatory-care-setting
June 01, 2022 - An official website of the Department of Health & Human Services
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-patient-guide.pdf
June 02, 2025 - A Patient’s Guide to Warm Handoffs
Why is it important?
A warm handoff:
■ Lets you hear what your providers are saying
about your health and your plan of care.
■ Encourages you to speak up, ask questions,
and join the conversation about your health.
■ Gives you a chance to correct or clarify
any information…
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psnet.ahrq.gov/issue/qualitative-study-why-general-practitioners-may-participate-significant-event-analysis-and
October 29, 2008 - Study
A qualitative study of why general practitioners may participate in significant event analysis and educational peer assessment.
Citation Text:
Bowie P, McKay J, Dalgetty E, et al. A qualitative study of why general practitioners may participate in significant event analysis and e…
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www.ahrq.gov/evidencenow/projects/heart-health/research-results/research/evaluation-design.html
March 01, 2021 - Evaluation Design and Methods
Evaluation Design
Each of the EvidenceNOW Cooperatives’ evaluation teams set out to determine the effectiveness of their external support interventions, using a range of mixed-methods designs. The cooperatives were asked to capture a core set of measures of A spirin use, B loo…
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psnet.ahrq.gov/issue/misleading-one-detail-preventable-mode-diagnostic-error
February 10, 2016 - Study
Misleading one detail: a preventable mode of diagnostic error?
Citation Text:
Arzy S, Brezis M, Khoury S, et al. Misleading one detail: a preventable mode of diagnostic error? J Eval Clin Pract. 2009;15(5):804-6. doi:10.1111/j.1365-2753.2008.01098.x.
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