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psnet.ahrq.gov/issue/examining-effect-quality-improvement-initiatives-decreasing-racial-disparities-maternal
May 11, 2022 - Study
Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity.
Citation Text:
Davidson C, Denning S, Thorp K, et al. Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity. BMJ …
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psnet.ahrq.gov/issue/25-year-summary-us-malpractice-claims-diagnostic-errors-1986-2010-analysis-national
July 17, 2019 - Study
25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank.
Citation Text:
Tehrani ASS, Lee HW, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the N…
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psnet.ahrq.gov/issue/use-patient-complaints-identify-diagnosis-related-safety-concerns-mixed-method-evaluation
April 13, 2022 - Study
Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.
Citation Text:
Giardina TD, Korukonda S, Shahid U, et al. Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation. BMJ Qual Saf. 2021;30(12…
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psnet.ahrq.gov/issue/facilitators-and-barriers-care-transitions-comparing-perspectives-hospital-and-community
July 21, 2021 - Study
Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff.
Citation Text:
Carman E-M, Fray M, Waterson P. Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staf…
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psnet.ahrq.gov/issue/hemodialysis-bleeding-events-and-deaths-18-year-retrospective-analysis-patient-safety-and
June 23, 2021 - Study
Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.
Citation Text:
Walton E, Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: an 18-year retrospectiv…
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/monitor-patient-outcomes
August 01, 2025 - An official website of the Department of Health & Human Services
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psnet.ahrq.gov/issue/impact-diagnostic-decision-support-system-consultation-perceptions-gps-and-patients
June 28, 2017 - Study
The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients.
Citation Text:
Porat T, Delaney B, Kostopoulou O. The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients. BMC Med Inform Decis M…
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psnet.ahrq.gov/issue/structured-approach-ehr-surveillance-diagnostic-error-acute-care-exploratory-analysis-two
October 16, 2024 - Study
A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.
Citation Text:
Malik MA, Motta-Calderon D, Piniella N, et al. A structured approach to EHR surveillance of diagnostic error in acute car…
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psnet.ahrq.gov/issue/diagnostic-accuracy-physician-staffed-emergency-medical-teams-retrospective-observational
December 22, 2021 - Study
Diagnostic accuracy of physician-staffed emergency medical teams: a retrospective observational cohort study of prehospital versus hospital diagnosis in a 10-year interval.
Citation Text:
Schewe J-C, Kappler J, Dovermann K, et al. Diagnostic accuracy of physician-staffed emergency …
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psnet.ahrq.gov/issue/structured-override-reasons-drug-drug-interaction-alerts-electronic-health-records
April 29, 2018 - Study
Structured override reasons for drug–drug interaction alerts in electronic health records.
Citation Text:
Wright A, McEvoy D, Aaron S, et al. Structured override reasons for drug-drug interaction alerts in electronic health records. J Am Med Info Asso. 2019;26(10):934-942. doi:10.1…
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psnet.ahrq.gov/issue/longitudinal-study-clinical-peer-reviews-impact-quality-and-safety-us-hospitals
March 29, 2023 - Study
A longitudinal study of clinical peer review's impact on quality and safety in US hospitals.
Citation Text:
Edwards MT. A longitudinal study of clinical peer review's impact on quality and safety in U.S. hospitals. J Healthc Manag. 2013;58(5):369-85.
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psnet.ahrq.gov/issue/nature-and-timing-incidents-intercepted-surpass-checklist-surgical-patients
September 20, 2011 - Study
Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients.
Citation Text:
de Vries EN, Prins HA, Bennink C, et al. Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients. BMJ Qual Saf. 2012;21(6):503-8. doi:10.1136/…
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psnet.ahrq.gov/issue/differences-between-methods-detecting-medication-errors-secondary-analysis-medication
December 18, 2019 - Study
Emerging Classic
Differences between methods of detecting medication errors: a secondary analysis of medication administration errors using incident reports, the Global Trigger Tool method, and observations.
Citation Text:
Härkänen M, Turunen H, Vehviläine…
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psnet.ahrq.gov/issue/rates-serious-surgical-errors-california-and-plans-prevent-recurrence
March 09, 2022 - Study
Rates of serious surgical errors in California and plans to prevent recurrence.
Citation Text:
Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent recurrence. JAMA Netw Open. 2021;4(5):e217058. doi:10.1001/jamanetworkopen.2021.7058. …
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psnet.ahrq.gov/issue/lessons-learned-implementing-complex-and-innovative-patient-safety-learning-laboratory
August 03, 2022 - Study
Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center
Citation Text:
Businger AC, Fuller TE, Schnipper JL, et al. Lessons learned implementing a complex and innovative patient safety learning laboratory p…
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psnet.ahrq.gov/issue/cross-sectional-observational-study-high-override-rates-drug-allergy-alerts-inpatient-and
July 02, 2019 - Study
A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outpatient settings, and opportunities for improvement.
Citation Text:
Slight SP, Beeler PE, Seger DL, et al. A cross-sectional observational study of high override rates of drug al…
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digital.ahrq.gov/sites/default/files/docs/workflowtoolkit/WhatIsWorkflow.ppt
January 01, 2009 - How Do I Evaluate Workflow?
What is Workflow?
Defining workflow
Definitions of workflow vary. Here are a couple:
The flow of work through space and time, where work is comprised of three components: inputs are transformed into outputs.[1]
The activities, tools, and processes needed to produce or modify work, pr…
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psnet.ahrq.gov/issue/diagnostic-error-medicine-analysis-583-physician-reported-errors
June 24, 2009 - Study
Classic
Diagnostic error in medicine: analysis of 583 physician-reported errors.
Citation Text:
Schiff G, Hasan O, Kim S, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009;169(20):1881-1887. doi:10.1001/a…
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psnet.ahrq.gov/issue/patient-initiated-voluntary-online-survey-adverse-medical-events-perspective-696-injured
May 20, 2020 - Study
Classic
A patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured patients and families.
Citation Text:
Southwick FS, Cranley NM, Hallisy JA. A patient-initiated voluntary online survey of adverse medical events:…
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psnet.ahrq.gov/issue/notification-abnormal-lab-test-results-electronic-medical-record-do-any-safety-concerns
April 04, 2011 - Study
Classic
Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?
Citation Text:
Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safet…