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psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
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psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events
April 17, 2024 - Study
Putting the "action" in RCA(2): an analysis of intervention strength after adverse events.
Citation Text:
Zerillo JA, Tardiff SA, Flood D, et al. Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. Jt Comm J Qual Patient Saf. 2024;50(7):492-49…
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psnet.ahrq.gov/node/45370/psn-pdf
July 27, 2016 - Correct use of inhalers: help patients breathe easier.
July 27, 2016
ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.
https://psnet.ahrq.gov/issue/correct-use-inhalers-help-patients-breathe-easier
Patients and clinicians can make medication administration mistakes when new drug delivery mecha…
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia
Citation Text:
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citation
…
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hcup-us.ahrq.gov/db/state/siddist/2010_2011ARSIDCDDoc071414.pdf
January 01, 2010 - The HCUP Central Distributor State Inpatient Databases (SID) for Arkansas 2010 and 2011
contain incorrect expected payer information for two hospitals in 2010 (exactly 4 percent of all
discharges) and five hospitals in 2011 (about one percent of all discharges). The 2010 and 2011
AR SID have been recreated with corr…
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psnet.ahrq.gov/node/49791/psn-pdf
April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the
Preventable
April 1, 2017
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
The Case
An 84-year-old wo…
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/impaired-visual-acuity-in-older-adults-screening-2009
July 15, 2009 - visual condition compared with ophthalmologic examination, and 1 study reported that geriatricians correctly
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - Annual Perspective
Rethinking Root Cause Analysis
Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD | January 1, 2016
View more articles from the same authors.
Citation Text:
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. Rockville (MD): Age…
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effectivehealthcare.ahrq.gov/sites/default/files/selecting-evidence-quiz.ppt
May 29, 2025 - Quantitative Synthesis II: Interactive Quiz
When To Select Observational Studies
Interactive Quiz
Prepared for:
The Agency for Healthcare Research and Quality (AHRQ)
Training Modules for Systematic Reviews Methods Guide
www.ahrq.gov
When To Select Observational Studies Interactive Quiz
When should observational …
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/selecting-evidence-quiz.ppt
May 29, 2025 - Quantitative Synthesis II: Interactive Quiz
When To Select Observational Studies
Interactive Quiz
Prepared for:
The Agency for Healthcare Research and Quality (AHRQ)
Training Modules for Systematic Reviews Methods Guide
www.ahrq.gov
When To Select Observational Studies Interactive Quiz
When should observational …
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psnet.ahrq.gov/issue/surgical-confusions-ophthalmology
November 16, 2022 - Study
Surgical confusions in ophthalmology.
Citation Text:
Simon JW, Ngo Y, Khan S, et al. Surgical confusions in ophthalmology. Arch Ophthalmol. 2007;125(11):1515-22.
Copy Citation
Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/friedman-cp-et-al-1999
January 01, 1999 - Friedman CP et al. 1999 "Enhancement of clinicians' diagnostic reasoning by computer-based consultation - a multisite study of 2 systems."
Reference
Friedman CP, Elstein AS, Wolf FM, et al. Enhancement of clinicians' diagnostic reasoning by computer-based consultation - a multisite study of 2 systems.…
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psnet.ahrq.gov/issue/intraoperative-communications-between-pathologists-and-surgeons-do-we-understand-each-other
June 28, 2023 - Study
Intraoperative communications between pathologists and surgeons: do we understand each other?
Citation Text:
Wiggett A, Fischer G. Intraoperative communications between pathologists and surgeons: do we understand each other? Arch Pathol Lab Med. 2023;147(8):933-939. doi:10.5858/arp…
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cds.ahrq.gov/sites/default/files/cds/artifact/1071/2024_Data_Requirements_Healthy_Diet_and_Physical_Activity.xlsx
January 01, 2024 - FHIR DSTU2 Data Requirements
FHIR DSTU2 Data Requirements: Healthy Diet and Physical Activity for CVD Prevention
This spreadsheet was created to assist with integration efforts (i.e., integrating the interoperable logic with a health IT system). It provides details about each clinical concept included in the CDS exp…
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digital.ahrq.gov/sites/default/files/docs/citation/AppendixE_HIT_Hazard_Manager_Beta_Test.pdf
June 16, 2021 - Health IT Hazard Manager Beta-Test Appendix E. Inter-Rater Cognitive Testing Results
Appendix E – Inter-Rater Cognitive Testing Results
This appendix summarizes the hazard entries created by the seven test sites to describe the
six hazard scenarios. The category headings are the beta version categories.
1. D…
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psnet.ahrq.gov/node/49572/psn-pdf
October 01, 2008 - The Commentary
Correctly identifying a patient seems like a straightforward task.
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psnet.ahrq.gov/node/35868/psn-pdf
July 10, 2008 - Incidence, patterns, and prevention of wrong-site surgery.
July 10, 2008
Kwaan MR, Studdert DM, Zinner MJ, et al. Incidence, patterns, and prevention of wrong-site surgery. Arch
Surg. 2006;141(4):353-358.
https://psnet.ahrq.gov/issue/incidence-patterns-and-prevention-wrong-site-surgery
This AHRQ-supported study an…
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psnet.ahrq.gov/node/49766/psn-pdf
August 21, 2016 - Getting the (Right) Doctor, Right Away
August 21, 2016
Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
The Case
A 57-year-old woman with a history of chronic obstructive pulmonary disease underwent hip surgery.
Postop…
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digital.ahrq.gov/sites/default/files/docs/citation/AppendixF_HIT_Hazard_Manager_Beta_Test.pdf
June 16, 2021 - Health IT Hazard Manager Beta-Test Appendix F: “Other (specify)” Entries
Appendix F – “Other (specify)” Entries
Several questions in the beta Hazard Manager Discovery¸ Causation, Impact, Corrective
Action, and Vetting and Resolution tabs permitted participants to select “Other” and write their
response in a …
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan93/impaired-visual-acuity-in-older-adults-screening-2016
September 27, 2014 - Share to Facebook
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archived
Final Research Plan
Impaired Visual Acuity in Older Adults: Screening
September 27, 2014
Recommendations made by the USPSTF are independent of the U.S. government. T…