- 
                                        
digital.ahrq.gov/sites/default/files/User%20Guide_SMD%20Planning_%20Implementation_%20Reporting_508.pdf
August 01, 2023 - CDS 
development and justify that decision.19 This can include disease-specific conceptual models or 
behavior … patient-centered implementation frameworks, such as the 
Analytic Framework for Action,20 or patient-focused behavior … August 2023 
 Implementers can test PC CDS rules against patient data to detect unexpected PC CDS 
behavior
                                     
                                                                    - 
                                        
psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - which information is 
exchanged between individuals through a common system of 
symbols, signs, or behaviors
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/156-what-are-4es.pptx
October 01, 2024 - Changing attitudes and behaviors
Foster open communication channels.
Encourage collaboration.
                                     
                                                                    - 
                                        
www.ahrq.gov/diagnostic-safety/research/grants-2022.html
August 01, 2025 - The goal of the Safety-II Together Diagnostic Center of Excellence is to identify specific teaming behaviors
                                     
                                                                    - 
                                        
cdsic.ahrq.gov/sites/default/files/2024-09/CDSiC%20Chart%20Book%202024_508.pdf
January 01, 2024 - formats20 
• Researchers using empathy interviews with clinicians to 
understand clinician prescribing behaviors
                                     
                                                                    - 
                                        
www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-slides.html
December 01, 2017 - Build effective communication behaviors.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/33842/psn-pdf
January 01, 2018 - monitoring user activity logs (21), system error logs, and system performance to identify
anomalous behaviors
                                     
                                                                    - 
                                        
psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
November 03, 2025 - Team reflexivity represents the way individuals and team members collectively reflect on actions and behaviors
                                     
                                                                    - 
                                        
digital.ahrq.gov/sites/default/files/CDSiC%20Chart%20Book%202024_508.pdf
May 08, 2023 - formats20 
• Researchers using empathy interviews with clinicians to 
understand clinician prescribing behaviors
                                     
                                                                    - 
                                        
effectivehealthcare.ahrq.gov/sites/default/files/related_files/evidence-map-hcbs-protocol.pdf
July 27, 2023 - Evidence Map on Home and Community Based Services
 
 
Evidence-based Practice Center Technical Brief Protocol  
 
Project Title: Evidence Map on Home and Community Based Services 
 
 
I. Background and Objectives 
One in four adults in the United States live with some form of disability that impacts their 
cognit… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/837791/psn-pdf
August 05, 2022 - Patient Safety in the Ambulatory Care Setting
August 5, 2022
Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet].
2022.
https://psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
Introduction
There is no way to review the year 2021 in quality and … 
                                     
                                                                    - 
                                        
effectivehealthcare.ahrq.gov/sites/default/files/s5.pdf
October 01, 2007 - They arise from
differences in populations, prescribers’ behaviors, and con-
founding by indication or
                                     
                                                                    - 
                                        
effectivehealthcare.ahrq.gov/sites/default/files/arcia-presentation.pdf
October 08, 2025 - Arcia-notes-Teresa
First, I'd like to acknowledge my colleagues, Dr. Sue Bakken is my mentor and	
   is the PI of 
one of the major projects I'll be talking about today. 
1 
And	
  here you	
  can	
  also see our funding sources. 
2 
Today I'm going to talk about some of the opportunities that technology crea… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - fatigue, distraction, or other causes of momentary lapses in concentration and failures in automatic behaviors
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - May 8, 2024 
 
 
 
 
 
 
 
 Physician behaviors associated with increased physician and nurse communication
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) … 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/empty-bag
June 01, 2018 - also help reduce mismatches between the knowledge and expectations of those providing drugs and the behaviors
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - are not likely to result in lasting improvements, ongoing efforts to change both the attitudes and behaviors
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - Advancing Patient Safety Through State Reporting Systems 
 Jill Rosenthal, MPH | June 1, 2007 
                       
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for… 
                                     
                                                                    - 
                                        
digital.ahrq.gov/sites/default/files/docs/citation/k08hs024134-smith-final-report-2019.pdf
January 01, 2019 - Developing an Interactive, Patient-Centered mHealth Tool to Enhance Post-Cystectomy Care - Final Report
 
 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
ACKNOWLEDGMENT OF  AGENCY SUPPORT  
$464,524  
  
  
FINAL PROGRESS REPORT 
TITLE OF PROJECT 
Developing an Interactive, Patient-Centered mHealth Tool to Enhance Post…