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psnet.ahrq.gov/issue/effect-clinical-decision-support-pending-laboratory-results-emergency-department-discharge
April 24, 2018 - Study
The effect of a clinical decision support for pending laboratory results at emergency department discharge.
Citation Text:
Driver BE, Scharber SK, Fagerstrom ET, et al. The Effect of a Clinical Decision Support for Pending Laboratory Results at Emergency Department Discharge. J Eme…
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psnet.ahrq.gov/issue/interpreting-and-coding-causal-relationships-quality-and-safety-using-icd-11
November 15, 2017 - Commentary
Interpreting and coding causal relationships for quality and safety using ICD-11.
Citation Text:
Januel J-M, Southern DA, Ghali WA. Interpreting and coding causal relationships for quality and safety using ICD-11. BMC Med Inform Decis Mak. 2023;21(Suppl 6):385. doi:10.1186/s12…
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psnet.ahrq.gov/issue/deficiencies-quality-management-processes-and-delays-communication-test-results-and-follow
March 01, 2023 - Book/Report
Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.
Citation Text:
Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Fol…
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psnet.ahrq.gov/issue/crying-wolf-alarm-safety-and-management-paediatrics-scoping-review
April 24, 2018 - Review
Crying wolf, alarm safety and management in paediatrics: a scoping review.
Citation Text:
Cole R, Roderick G, Cheema O, et al. Crying wolf, alarm safety and management in paediatrics: a scoping review. J Adv Nurs. 2024;Epub Sep 25. doi:10.1111/jan.16398.
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psnet.ahrq.gov/issue/drug-related-problems-medical-wards-computerized-physician-order-entry-system
December 01, 2010 - Study
Drug-related problems in medical wards with a computerized physician order entry system.
Citation Text:
Bedouch P, Allenet B, Grass A, et al. Drug-related problems in medical wards with a computerized physician order entry system. J Clin Pharm Ther. 2009;34(2):187-95. doi:10.1111…
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psnet.ahrq.gov/issue/prescribers-interactions-medication-alerts-point-prescribing-multi-method-situ-investigation
January 07, 2015 - Study
Prescribers' interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the human–computer interaction.
Citation Text:
Russ AL, Zillich AJ, McManus S, et al. Prescribers' interactions with medication alerts at the point of prescribin…
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psnet.ahrq.gov/issue/hospital-acquired-sars-cov-2-infection-lessons-public-health
November 25, 2020 - Commentary
Hospital-acquired SARS-CoV-2 infection: lessons for public health.
Citation Text:
Richterman A, Meyerowitz EA, Cevik M. Hospital-acquired SARS-CoV-2 infection: lessons for public health. JAMA. 2020;324(21):2155. doi:10.1001/jama.2020.21399.
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psnet.ahrq.gov/issue/impact-patient-safety-bundle-and-team-based-training-obstetric-hypertensive-emergencies
July 21, 2021 - Study
Impact of patient safety bundle and team-based training on obstetric hypertensive emergencies.
Citation Text:
Grogan L, Peterson E, Flatley M, et al. Impact of patient safety bundle and team-based training on obstetric hypertensive emergencies. Am J Perinatol. 2025;42(4):452-461. d…
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psnet.ahrq.gov/issue/sepsis-alert-systems-mortality-and-adherence-emergency-departments-systematic-review-and-meta
September 06, 2017 - Review
Sepsis alert systems, mortality, and adherence in emergency departments: a systematic review and meta-analysis.
Citation Text:
Kim H-J, Ko R-E, Lim SY, et al. Sepsis alert systems, mortality, and adherence in emergency departments: a systematic review and meta-analysis. JAMA Netw …
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psnet.ahrq.gov/issue/effects-racial-bias-pulse-oximetry-children-and-how-address-algorithmic-bias-clinical
May 08, 2017 - Commentary
Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine.
Citation Text:
Gray KD, Subramaniam HL, Huang ES. Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine. JAMA …
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psnet.ahrq.gov/issue/morbidity-and-mortality-conference-picus-united-states-national-survey
October 20, 2014 - Study
The morbidity and mortality conference in PICUs in the United States: a national survey.
Citation Text:
Cifra CL, Bembea MM, Fackler JC, et al. The morbidity and mortality conference in PICUs in the United States: a national survey. Crit Care Med. 2014;42(10):2252-7. doi:10.1097/CC…
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psnet.ahrq.gov/issue/rapid-response-systems-and-collective-incompetence-exploratory-analysis-intraprofessional-and
June 19, 2012 - Study
Rapid response systems and collective (in)competence: an exploratory analysis of intraprofessional and interprofessional activation factors.
Citation Text:
Kitto S, Marshall SD, McMillan SE, et al. Rapid response systems and collective (in)competence: An exploratory analysis of int…
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psnet.ahrq.gov/issue/interventions-reduce-nurses-medication-administration-errors-inpatient-settings-systematic
October 13, 2021 - Review
Interventions to reduce nurses' medication administration errors in inpatient settings: a systematic review and meta-analysis.
Citation Text:
Berdot S, Roudot M, Schramm C, et al. Interventions to reduce nurses' medication administration errors in inpatient settings: A systematic …
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psnet.ahrq.gov/issue/associations-physician-burnout-career-engagement-and-quality-patient-care-systematic-review
February 02, 2022 - Review
Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis.
Citation Text:
Hodkinson A, Zhou, A, Johnson J, et al. Associations of physician burnout with career engagement and quality of patient care: systematic review…
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psnet.ahrq.gov/issue/association-state-level-opioid-reduction-policies-pediatric-opioid-poisoning
September 09, 2020 - Study
Association of state-level opioid-reduction policies with pediatric opioid poisoning.
Citation Text:
Toce MS, Michelson K, Hudgins J, et al. Association of state-level opioid-reduction policies with pediatric opioid poisoning. JAMA Pediatr. 2020;74(10):961-968. doi:10.1001/jamapedi…
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psnet.ahrq.gov/issue/morbidity-and-mortality-conferences-narrative-review-strategies-prioritize-quality
January 11, 2023 - Review
Morbidity and mortality conferences: a narrative review of strategies to prioritize quality improvement.
Citation Text:
Giesbrecht V, Au S. Morbidity and Mortality Conferences: A Narrative Review of Strategies to Prioritize Quality Improvement. Jt Comm J Qual Patient Saf. 2016;42(…
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psnet.ahrq.gov/issue/impact-percentage-overlapping-surgery-patient-outcomes-retrospective-cohort-study-87000
February 22, 2019 - Review
Impact of the percentage of overlapping surgery on patient outcomes: a retrospective cohort study of 87,000 surgical cases.
Citation Text:
Pitts CC, Ponce BA, Arguello AM, et al. Impact of the percentage of overlapping surgery on patient outcomes: a retrospective cohort study of 8…
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psnet.ahrq.gov/issue/digital-health-intervention-patient-safety-children-and-parents-scoping-review
January 23, 2017 - Review
Digital health intervention on patient safety for children and parents: a scoping review.
Citation Text:
Park J, Jeon H, Choi EK. Digital health intervention on patient safety for children and parents: a scoping review. J Adv Nurs. 2024;80(5):1750-1760. doi:10.1111/jan.15954.
Co…
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psnet.ahrq.gov/issue/educational-targets-reduce-medication-errors-general-surgery-residents
October 19, 2022 - Study
Educational targets to reduce medication errors by general surgery residents.
Citation Text:
Chaitoff A, Strong AT, Bauer SR, et al. Educational Targets to Reduce Medication Errors by General Surgery Residents. J Surg Educ. 2019;76(6):1612-1621. doi:10.1016/j.jsurg.2019.04.009.
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www.ahrq.gov/news/newsroom/case-studies/201520.html
July 01, 2015 - Wisconsin Critical Access Hospital Sees Big Results with AHRQ’s CUSP, RED and TeamSTEPPS®
Search All Impact Case Studies
July 2015
Amery Hospital & Clinic, a 25-bed acute care critical access hospital in rural Wisconsin, used AHRQ’s Comprehensive Unit-based Safety Program (CUSP) to reduce surgical site in…