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61. AHRQ Transforming Primary Care Grants Bibliography | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/ncepcr/reports/grants-transform/bibliography/index.html
    February 01, 2017 - The authors concluded that these studies demonstrate that although PCMH transformation is challenging … PMID: 23690380 The authors examined contextual factors identified as important for interpreting and … The authors concluded that this work demonstrates the potential utility of identifying and reporting … Based on descriptive data focused on PCMH redesign, the authors determined that these small practices … PMID: 23690389 The authors examined changes in patterns of health care utilization and outcomes in

62. AHRQ Transforming Primary Care Grants | Agency for Healthcare Research and Quality
    preventiveservices.ahrq.gov/ncepcr/research-transform-primary-care/transform/tpcbib/index.html
    May 01, 2015 - The authors concluded that these studies demonstrate that although PCMH transformation is challenging … PMID: 23690380 The authors examined contextual factors identified as important for interpreting and … The authors concluded that this work demonstrates the potential utility of identifying and reporting … Based on descriptive data focused on PCMH redesign, the authors determined that these small practices … PMID: 23690389 The authors examined changes in patterns of health care utilization and outcomes in

63. An alternative strategy for studying adverse events in medical care. | PSNet
    psnet.ahrq.gov/issue/alternative-strategy-studying-adverse-events-medical-care
    June 03, 2020 - View more articles from the same authors. … The authors report an ethnographic study of adverse events  in medical care in two intensive care units … The authors suggest that their result, much higher than prior estimates, is more accurate than previous … The authors emphasize that 25% of detected errors had “interactive” or “administrative” causes, rather

64. Urinary Incontinence Primary Care Screening Workflow (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/mui/screening-workflow.pdf
    March 21, 2025 - The authors are solely responsible for this document’s contents, findings, and conclusions, which do … None of the authors has any affiliation or financial involvement that conflicts with the material presented

65. Incidence of adverse drug events and potential adverse drug events: implications for prevention. | PSNet
    psnet.ahrq.gov/issue/incidence-adverse-drug-events-and-potential-adverse-drug-events-implications-prevention
    February 10, 2011 - View more articles from the same authors. … The authors report on their seminal 1993 study of adverse drug events (ADEs) at the Massachusetts General … Using 11 intensive and general care units at the two hospitals, the authors prospectively identified … The authors report an adjusted rate of ADEs of 6.5 per 100 admissions, 1.8 per 100 considered preventable … The authors break down ADEs by drug class and by the stage at which the error occurred (ordering, transcription

66. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. | PSNet
    psnet.ahrq.gov/issue/adverse-drug-events-hospitalized-patients-excess-length-stay-extra-costs-and-attributable
    February 10, 2011 - View more articles from the same authors. … The authors report a retrospective case-control study of adverse drug events (ADEs) at the LDS Hospital … The authors found a 1.74-day attributable increased length of stay and a $2014 (in 1997) attributable … The authors calculate a total attributable direct cost of ADEs of almost $4.5 million during the 3-year … The authors review the potential generalizability of their automated detection techniques and the potential

67. Computerized surveillance of adverse drug events in hospital patients. | PSNet
    psnet.ahrq.gov/issue/computerized-surveillance-adverse-drug-events-hospital-patients
    March 27, 2005 - View more articles from the same authors. … The authors report on an extension of the HELP clinical information system at LDS Hospital, Salt Lake … The authors describe a rule-based approach wherein certain medications (such as naloxone or diphenhydramine … Concurrently, the authors provided an enhanced online system for traditional voluntary incident reporting … The authors describe a 60-fold increase in detection of ADEs with the automated system relative to voluntary

68. Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/studies/index.html?page=116
    January 01, 2024 - The authors have developed a comprehensive, multilevel framework to inform learning health systems (LHSs … The authors sought to measure pediatric preventive counseling at patient-centered medical homes (PCMHs … The authors describe all-cause harm among patients from PA/LTC setting seen in the ED. … The authors linked clinical and internal cost data for patients undergoing CABG from 2014 to 2017 at … The authors urge that COVID-19-focused research consider racial and ethnic disparity.

69. Urinary Incontinence Clinician Pocket Guide (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/projects/urinary/pursuit-clinician-pocket-guide.pdf
    November 28, 2023 - The authors are solely responsible for this document’s contents, findings, and conclusions, which do … None of the authors has any affiliation or financial involvement that conflicts with the material presented

70. Making hospital care safer and better: the structure-process connection leading to adverse events. | PSNet
    psnet.ahrq.gov/issue/making-hospital-care-safer-and-better-structure-process-connection-leading-adverse-events
    November 04, 2020 - View more articles from the same authors. … The authors propose a model for identifying factors that contribute to adverse events in hospital care … Using secondary data from a large Canadian nursing survey, the authors found that perceived understaffing

71. Errors and omissions in anesthesia: a pilot study using a pilot's checklist. | PSNet
    psnet.ahrq.gov/issue/errors-and-omissions-anesthesia-pilot-study-using-pilots-checklist
    September 23, 2020 - View more articles from the same authors. … The authors tested the efficacy of using a verbal checklist to prepare anesthesiologists to give general … Most participants found the checklist to be useful, and the authors conclude that the tool could improve

72. Public sector organizational failure: a study of collective denial in the UK national health service. | PSNet
    psnet.ahrq.gov/issue/public-sector-organizational-failure-study-collective-denial-uk-national-health-service
    June 03, 2020 - View more articles from the same authors. … Using the events at the United Kingdom’s Mid Staffordshire Trust hospital as a case study, the authors … The authors suggest that safeguards allowing for self-reflection and correction be implemented early

73. SEIPS 3.0: human-centered design of the patient journey for patient safety. | PSNet
    psnet.ahrq.gov/issue/seips-30-human-centered-design-patient-journey-patient-safety
    September 11, 2019 - View more articles from the same authors. … The authors propose a SEIPS 3.0 model which would include the patient journey, defined by the authors

74. What is safety leadership? A systematic review of definitions. | PSNet
    psnet.ahrq.gov/issue/what-safety-leadership-systematic-review-definitions
    October 26, 2022 - View more articles from the same authors. … Transformational and transactional leadership formed the foundation for many definitions, though the authors … The authors propose that future research focus on the relationship between leadership style and safety

75. Detecting adverse drug reactions on paediatric wards: intensified surveillance versus computerised screening of laboratory values. | PSNet
    psnet.ahrq.gov/issue/detecting-adverse-drug-reactions-paediatric-wards-intensified-surveillance-versus
    May 10, 2023 - View more articles from the same authors. … approaches to collect data, an intensified surveillance system and computer-assisted screening, the authors … The authors determined that ADRs occur as frequently in pediatric patients as in adult patients and that

76. Clinical reasoning in the wild: premature closure during the COVID-19 pandemic. | PSNet
    psnet.ahrq.gov/issue/clinical-reasoning-wild-premature-closure-during-covid-19-pandemic
    September 02, 2020 - View more articles from the same authors. … In this Letter to the Editor, the authors suggest that the COVID-19 pandemic presents a unique opportunity … The authors discuss the potential implications through a clinical story involving a redeployed resident

77. Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/studies/index.html?page=363
    January 01, 2024 - The authors aimed to characterize patients' use of communication mechanisms within Facebook for health … The authors investigated how the Internet is used to obtain health-related information and how individuals … The authors argue that a rethinking of elective colectomy should come from a patient-centered approach … The authors estimated the risk of infective endocarditis (IE) after colonoscopy in individuals aged 70 … The authors concluded that a curriculum designed specifically for surgeons may enable future programs

78. Disposition of Comments: Comparative Effectiveness Review No. 234_Management of Primary Headaches in Pregnancy (pdf file)
    effectivehealthcare.ahrq.gov/sites/default/files/cer-234-headaches-pregnancy-comments.pdf
    November 12, 2020 - Comments on draft reviews and the authors’ responses to the comments are posted for public viewing on … Evidence-based Practice Center (EPC) authors made these changes. … EPC authors included both studies. … EPC authors added those details to the Discussion. … EPC authors made these changes.

79. Prologue: Technology and Medication Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Prologue_Grady_Vol4.pdf
    July 25, 2008 - Other authors focus on the challenges that must be faced and overcome if we are to make the most of … Other authors describe the positive effects of computerized provider order entry (CPOE) on turnaround … Concerns about confidentiality and system reliability are addressed by several groups of authors. … Authors in this section approach the problem of medication safety from several different angles. … One group of authors examined the feasibility of detecting medication errors through self-observation

80. A piece of my mind. Coping with fallibility. | PSNet
    psnet.ahrq.gov/issue/piece-my-mind-coping-fallibility
    June 26, 2015 - View more articles from the same authors. … The authors relate personal experiences with physician error, including the professional and emotional … The authors argue for increased discussion of errors among physicians, both as an educational exercise … The authors suggest physician leaders in an organization can improve organizational culture by setting