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www.ahrq.gov/hai/cusp/toolkit/observing-rounds.html
December 01, 2012 - Observing Patient Care Rounds
CUSP Toolkit
Communication among disciplines can be improved if viewed through the eyes of an objective observer.
Problem statement: Interdisciplinary rounds are in the best interest of patients. Poor communication among staff is a root cause of many patient adverse and sentin…
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digital.ahrq.gov/ahrq-funded-projects/use-ehr-metadata-assess-hospital-discharge-planning-post-acute-transitions
January 31, 2025 - Use of Electronic Health Record Metadata to Assess Hospital Discharge Planning for Post-Acute Transitions
Project Description
Publications
Analyzing electronic health record metadata may help health systems identify gaps, inconsistencies, and inefficiencies in discharge p…
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psnet.ahrq.gov/issue/becoming-high-reliability-organization-through-shared-learning-safety-events
February 12, 2020 - Newspaper/Magazine Article
Becoming a high-reliability organization through shared learning of safety events
Citation Text:
Becoming a high-reliability organization through shared learning of safety events Klenklen J. Patient Saf Qual HCare. December 19, 2019.
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www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/reports-congress/sixth-annual-report-congress-high-priority-evidence-gaps-clinical-preventive-services
December 01, 2017 - Sixth Annual Report to Congress on High-Priority Evidence Gaps for Clinical Preventive Services
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The U.S. Preventive Services Task Force (USPSTF or Task Force) has released it…
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psnet.ahrq.gov/issue/adverse-glycemic-events-and-critical-emergencies
December 14, 2022 - Newspaper/Magazine Article
Adverse glycemic events and critical emergencies.
Citation Text:
Adverse glycemic events and critical emergencies. ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4.
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psnet.ahrq.gov/issue/seeing-systems-health-care-organizations
January 25, 2023 - Commentary
Seeing systems in health care organizations.
Citation Text:
Friedman LH, King JB, Bella D. Seeing systems in health care organizations. Physician Exec. 2007;33(4):20-9.
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psnet.ahrq.gov/issue/mindless-mindful-practice-cognitive-bias-and-clinical-decision-making
November 23, 2016 - Commentary
From mindless to mindful practice—cognitive bias and clinical decision making.
Citation Text:
Croskerry P. From mindless to mindful practice--cognitive bias and clinical decision making. N Engl J Med. 2013;368(26):2445-2448. doi:10.1056/NEJMp1303712.
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psnet.ahrq.gov/issue/do-not-let-depo-medications-be-depot-mistakes
March 15, 2022 - Newspaper/Magazine Article
Do not let "Depo-" medications be a depot for mistakes.
Citation Text:
Do not let "Depo-" medications be a depot for mistakes. ISMP Medication Safety Alert! Acute Care Edition. March 24, 2016;21:1-4.
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psnet.ahrq.gov/issue/piece-my-mind-mentorship-malpractice
September 16, 2020 - Commentary
A piece of my mind. Mentorship malpractice.
Citation Text:
Chopra V, Edelson DP, Saint S. A PIECE OF MY MIND. Mentorship Malpractice. JAMA. 2016;315(14):1453-4. doi:10.1001/jama.2015.18884.
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psnet.ahrq.gov/issue/mean-girls-er-alarming-nurse-culture-bullying-and-hazing
November 01, 2017 - Newspaper/Magazine Article
Mean girls of the ER: the alarming nurse culture of bullying and hazing.
Citation Text:
Mean girls of the ER: the alarming nurse culture of bullying and hazing. Robbins A. Good Housekeeping. May 20, 2016.
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psnet.ahrq.gov/issue/pump-volume-tips-increasing-error-reporting-and-decreasing-patient-harm
January 27, 2021 - Newspaper/Magazine Article
Pump up the volume: tips for increasing error reporting and decreasing patient harm.
Citation Text:
Pump up the volume: tips for increasing error reporting and decreasing patient harm. ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5…
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psnet.ahrq.gov/issue/doctors-are-more-dangerous-gun-owners-rejoinder-error-counting
June 24, 2020 - Commentary
Doctors are more dangerous than gun owners: a rejoinder to error counting.
Citation Text:
Dekker SWA. Doctors are more dangerous than gun owners: a rejoinder to error counting. Hum Factors. 2007;49(2):177-84.
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psnet.ahrq.gov/issue/cultural-issues-related-allegations-bullying-and-harassment-nhs-highland-independent-review
July 29, 2015 - Government Resource
Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.
Citation Text:
Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report. Sturrock J. Edinburgh, Scotland: …
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psnet.ahrq.gov/issue/ismp-canada-identifies-themes-associated-fatal-medication-events-home
March 15, 2022 - Newspaper/Magazine Article
ISMP Canada identifies themes associated with fatal medication events in the home.
Citation Text:
ISMP Canada identifies themes associated with fatal medication events in the home. ISMP Medication Safety Alert! Acute Care Edition. February 27, 2014;19:1-4. …
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psnet.ahrq.gov/issue/more-can-be-done-alleviate-errors-associated-pharmaceutical-product-labeling-and-packaging
May 03, 2023 - Newspaper/Magazine Article
More can be done to alleviate errors associated with pharmaceutical product labeling and packaging.
Citation Text:
More can be done to alleviate errors associated with pharmaceutical product labeling and packaging. ISMP Medication Safety Alert! Acute Care Editi…
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digital.ahrq.gov/national-webinars
October 08, 2025 - National Webinars
The AHRQ Digital Healthcare Research (DHR) Program sponsors national webinars showcasing the latest scientific advancements and key conversations with experts around impactful research in the evolving digital healthcare ecosystem. Access the latest on-demand webinars and up…
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psnet.ahrq.gov/issue/physician-perception-hospital-safety-and-barriers-incident-reporting
February 16, 2011 - Study
Physician perception of hospital safety and barriers to incident reporting.
Citation Text:
Schectman JM, Plews-Ogan M. Physician perception of hospital safety and barriers to incident reporting. Jt Comm J Qual Patient Saf. 2006;32(6):337-43.
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psnet.ahrq.gov/issue/survey-shows-room-improvement-two-new-ismp-targeted-medication-safety-best-practices
February 12, 2020 - Newspaper/Magazine Article
Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices.
Citation Text:
Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices. ISMP Medication Safety Alert! Acute care edition. July 3…
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psnet.ahrq.gov/issue/understanding-and-attitudes-towards-patient-safety-concepts-obstetrics
March 29, 2012 - Study
Understanding and attitudes towards patient safety concepts in obstetrics.
Citation Text:
Nabhan A, Ahmed-Tawfik MS. Understanding and attitudes towards patient safety concepts in obstetrics. Int J Gynaecol Obstet. 2007;98(3):212-6.
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psnet.ahrq.gov/issue/errors-and-analysis-errors
August 28, 2019 - Commentary
Errors and analysis of errors.
Citation Text:
Mulligan MA, Nechodom P. Errors and analysis of errors. Clin Obstet Gynecol. 2008;51(4):656-65. doi:10.1097/GRF.0b013e3181899a5a.
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