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  1. Handoffs causing patient harm: a survey of medical and surgical house staff. | PSNet

    psnet.ahrq.gov/issue/handoffs-causing-patient-harm-survey-medical-and-surgical-house-staff
    July 10, 2008 - Study Handoffs causing patient harm: a survey of medical and surgical house staff. Citation Text: Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34(10):563-70. Copy Citation Format:…

  2. Introduction | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-2.html
    June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Introduction Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Introduct…

  3. Implementing the New CAHPS® Protocol for Obtaining Patient Comments About Their Care (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/nyp-webinar-grob-narrative-elicitation-protocol.pdf
    June 02, 2025 - Implementing the New CAHPS® Protocol for Obtaining Patient Comments About Their Care The CAHPS Narrative Elicitation Protocol Rachel Grob, Ph.D. Director of National Initiatives and Clinical Professor, Center for Patient Partnerships Madison, WI www.ahrq.gov/cahps CAHPS Narrative Elicitation Protocol • A …

  4. Narrative feedback from OR personnel about the safety of their surgical practice before and after a surgical safety checklist intervention. | PSNet

    psnet.ahrq.gov/issue/narrative-feedback-or-personnel-about-safety-their-surgical-practice-and-after-surgical
    May 09, 2018 - Study Narrative feedback from OR personnel about the safety of their surgical practice before and after a surgical safety checklist intervention. Citation Text: Alidina S, Hur H-C, Berry WR, et al. Narrative feedback from OR personnel about the safety of their surgical practice before an…

  5. Appendix 2-B. Pre/Post-Test Questions and Answers for Module 2 | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap2b.html
    October 01, 2014 - Improving Patient Safety in Long-Term Care Facilities Appendix 2-B. Pre/Post-Test Questions and Answers for Module 2 Previous Page Next Page Table of Contents Improving Patient Safety in Long-Term Care Facilities Introduction Module 1. Detecting Change in a Resident's Condition Module 2. Commu…

  6. Patient-safety–related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. | PSNet

    psnet.ahrq.gov/issue/patient-safety-related-hospital-deaths-england-thematic-analysis-incidents-reported-national
    October 31, 2014 - Study Patient-safety–related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. Citation Text: Donaldson LJ, Panesar S, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national da…

  7. Iatrogenic events contributing to ICU admission: a prospective study. | PSNet

    psnet.ahrq.gov/issue/iatrogenic-events-contributing-icu-admission-prospective-study
    November 29, 2023 - Study Iatrogenic events contributing to ICU admission: a prospective study. Citation Text: Mercier E, Giraudeau B, Giniès G, et al. Iatrogenic events contributing to ICU admission: a prospective study. Intensive Care Med. 2010;36(6):1033-7. doi:10.1007/s00134-010-1793-9. Copy Citatio…

  8. Differential perceptions of what constitutes a medical error associated with electronic medical records. | PSNet

    psnet.ahrq.gov/issue/differential-perceptions-what-constitutes-medical-error-associated-electronic-medical-records
    August 09, 2023 - Commentary Differential perceptions of what constitutes a medical error associated with electronic medical records. Citation Text: Koppel R, Kuziemsky C, Elkin PL, et al. Differential perceptions of what constitutes a medical error associated with electronic medical records. Stud Health …

  9. Event Investigation and Analysis Guide: Appendix I | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/api.html
    August 01, 2022 - Event Investigation and Analysis Guide: Appendix I Glossary Adverse safety event: a deviation from generally accepted performance standards that reaches the patient and results in moderate to severe harm or death. Anchoring bias:   the tendency to make all information fit into a preconceived story, causing…

  10. A machine learning-based clinical predictive tool to identify patients at high risk of medication errors. | PSNet

    psnet.ahrq.gov/issue/machine-learning-based-clinical-predictive-tool-identify-patients-high-risk-medication-errors
    March 29, 2012 - Study A machine learning-based clinical predictive tool to identify patients at high risk of medication errors. Citation Text: Abdo A, Gallay L, Vallecillo T, et al. A machine learning-based clinical predictive tool to identify patients at high risk of medication errors. Sci Rep. 2024;14…

  11. Application of a digital quality measure for cancer diagnosis in Epic Cosmos. | PSNet

    psnet.ahrq.gov/issue/application-digital-quality-measure-cancer-diagnosis-epic-cosmos
    November 13, 2024 - Study Application of a digital quality measure for cancer diagnosis in Epic Cosmos. Citation Text: Zimolzak AJ, Khan SP, Singh H, et al. Application of a digital quality measure for cancer diagnosis in Epic Cosmos. J Am Med Inform Assoc. 2025;32(1):227-229. doi:10.1093/jamia/ocae253. C…

  12. Longitudinal analysis of culture of patient safety survey results in surgical departments. | PSNet

    psnet.ahrq.gov/issue/longitudinal-analysis-culture-patient-safety-survey-results-surgical-departments
    October 12, 2022 - Study Longitudinal analysis of culture of patient safety survey results in surgical departments. Citation Text: Butler LR, Lashani S, Mitchell C, et al. Longitudinal analysis of culture of patient safety survey results in surgical departments. Front Health Serv. 2024;4:1419248. doi:10.33…

  13. Evaluating iatrogenic prescribing: development of an oncology-focused trigger tool. | PSNet

    psnet.ahrq.gov/issue/evaluating-iatrogenic-prescribing-development-oncology-focused-trigger-tool
    December 23, 2020 - Study Evaluating iatrogenic prescribing: development of an oncology-focused trigger tool. Citation Text: Hébert G, Netzer F, Ferrua M, et al. Evaluating iatrogenic prescribing: development of an oncology-focused trigger tool. Eur J Cancer. 2015;51(3):427-35. doi:10.1016/j.ejca.2014.12.00…

  14. Improving patient safety in intensive care units in Michigan. | PSNet

    psnet.ahrq.gov/issue/improving-patient-safety-intensive-care-units-michigan
    February 17, 2011 - Study Classic Improving patient safety in intensive care units in Michigan. Citation Text: Pronovost P, Berenholtz SM, Goeschel CA, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-212. doi:10.1016/j.jcrc.2007.09…

  15. Seddbrochure 050218 (pdf file)

    hcup-us.ahrq.gov/news/exhibit_booth/SEDDBrochure_050218.pdf
    May 16, 2018 - What are the SEDD? The State Emergency Department Databases (SEDD) are part of the family of databases and software tools developed for the Healthcare Cost and Utilization Project (HCUP). The SEDD are a set of longitudinal State-specific emergency department databases included in the HCUP family. The SEDD capture disch…

  16. Adverse events in the operating room: definitions, prevalence, and characteristics. A systematic review. | PSNet

    psnet.ahrq.gov/issue/adverse-events-operating-room-definitions-prevalence-and-characteristics-systematic-review
    July 25, 2018 - Review Adverse events in the operating room: definitions, prevalence, and characteristics. A systematic review. Citation Text: Jung JJ, Elfassy J, Jüni P, et al. Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review. World J Surg. 2019;4…

  17. Examining the Feasibility and Effectiveness of an mHealth Solution Designed to Enhance Clinical Outcomes Among Patients Attending Physical Therapy for Musculoskeletal Pain | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/examining-feasibility-and-effectiveness-mhealth-solution-designed-enhance
    August 01, 2024 - Examining the Feasibility and Effectiveness of an mHealth Solution Designed to Enhance Clinical Outcomes Among Patients Attending Physical Therapy for Musculoskeletal Pain Project Description Improving patient engagement in physical therapy (PT) through remote therapeutic monit…

  18. A systematic review of patient-report safety climate measures in health care. | PSNet

    psnet.ahrq.gov/issue/systematic-review-patient-report-safety-climate-measures-health-care
    September 15, 2021 - Review A systematic review of patient-report safety climate measures in health care. Citation Text: Madden C, Lydon S, O’Dowd E, et al. A systematic review of patient-report safety climate measures in health care. J Patient Saf. 2022;18(1):e51-e60. doi:10.1097/pts.0000000000000705. Cop…

  19. Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative Database Report. | PSNet

    psnet.ahrq.gov/issue/community-pharmacy-survey-patient-safety-culture-2015-user-comparative-database-report
    November 30, 2016 - Book/Report Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative Database Report. Citation Text: Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative Database Report. Famolaro T, Yount N, Sorra J, et al. Rockville, MD: Agency for Healthcare Resea…

  20. Validating the Patient Safety Indicators in the Veterans Health Administration: do they accurately identify true safety events? | PSNet

    psnet.ahrq.gov/issue/validating-patient-safety-indicators-veterans-health-administration-do-they-accurately
    January 18, 2013 - Study Validating the Patient Safety Indicators in the Veterans Health Administration: do they accurately identify true safety events? Citation Text: Rosen AK, Itani KMF, Cevasco M, et al. Validating the Patient Safety Indicators in the Veterans Health Administration. Med Care. 2011;50(…
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