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psnet.ahrq.gov/issue/human-factors-engineering-healthcare-systems-problem-human-error-and-accident-management
June 13, 2011 - Commentary
Human factors engineering in healthcare systems: the problem of human error and accident management.
Citation Text:
Cacciabue PC, Vella G. Human factors engineering in healthcare systems: the problem of human error and accident management. Int J Med Inform. 2010;79(4):e1-17.…
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psnet.ahrq.gov/issue/interorganizational-complexity-and-organizational-accident-risk-literature-review
June 02, 2021 - Review
Interorganizational complexity and organizational accident risk: a literature review.
Citation Text:
Milch V, Laumann K. Interorganizational complexity and organizational accident risk: A literature review. Safety Sci. 2015;82:9-17. doi:10.1016/j.ssci.2015.08.010.
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psnet.ahrq.gov/issue/computerization-can-create-safety-hazards-bar-coding-near-miss
March 11, 2011 - Commentary
Classic
Computerization can create safety hazards: a bar-coding near miss.
Citation Text:
McDonald CJ. Computerization can create safety hazards: a bar-coding near miss. Ann Intern Med. 2006;144(7):510-6.
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www.ahrq.gov/cahps/surveys-guidance/item-sets/literacy/index.html
December 01, 2022 - CAHPS Health Literacy Item Sets
The CAHPS Health Literacy Item Sets ask about providers' efforts to foster and improve the health literacy of patients. Health literacy is commonly defined as patients' ability to obtain, process, and understand the basic health information and services they need to make appropri…
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digital.ahrq.gov/ahrq-funded-projects/implementation-ddinteract-shared-decision-making-tool-anticoagulant-drug-drug
August 15, 2023 - Implementation of DDInteract: A Shared Decision Making Tool for Anticoagulant Drug-Drug Interactions
Project Description
This research has the potential to reduce drug-drug interactions involving anticoagulants through a novel shared decision making tool that visually displays,…
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digital.ahrq.gov/pediatric-rules-and-reminders
January 01, 2023 - Pediatric Rules and Reminders
Executive Summary
Reminders are elements of clinical decision support (CDS) that can be an effective mechanism for improving adherence to clinical guidelines. Greater adherence can lead to improved health care quality and safety, especially for …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/no-more-cauti-preventing-cauti.pptx
June 02, 2025 - No More CAUTI – preventing catheter associated urinary tact infections
No More CAUTI – preventing catheter associated urinary tract infections
Elizabeth Mizerek, MSN, RN, CEN, CPEN, FN-CSA
Assistant Professor of Nursing
Mercer County Community College
1
1
Learning Objectives
Define the impact of CAUTI
Des…
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psnet.ahrq.gov/issue/what-causes-prescribing-errors-children-scoping-review
September 09, 2015 - Review
What causes prescribing errors in children? Scoping review.
Citation Text:
Conn RL, Kearney O, Tully MP, et al. What causes prescribing errors in children? Scoping review. BMJ Open. 2019;9(8):e028680. doi:10.1136/bmjopen-2018-028680.
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www.ahrq.gov/research/findings/evidence-based-reports/nutritn6tp.html
April 01, 2018 - Vol 6: Concordance Between the Findings of Epidemiological Studies and Randomized Trials in Nutrition: An Empirical Evaluation and Analysis
Structured Abstract
Full Title: Nutritional Research Series: Advancing the Role of Evidence-based Reviews in Nutrition Research and Applications
To facilitate a better …
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-intro-qi.pdf
June 02, 2025 - Job Aid: Introduction to Quality Improvement
Primary Care Practice Facilitator
Training Series
1
Job Aid: Introduction to Quality Improvement
Quality Improvement (QI) Basics
The QI Process
You will be helping practices to:
Identify areas for improvement.
Set goals.
Develop a plan that…
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www.ahrq.gov/gam/summaries/domain-framework/index.html
July 01, 2018 - NQMC Measure Domain Framework
The National Quality Measures Clearinghouse (NQMC) was a database of measures meeting specific criteria for inclusion. Measures in NQMC were classified into domains according to the domain framework below.
There are many dimensions of performance related to clinical health care d…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/or_briefing_audit.docx
December 01, 2017 - Tool: OR Briefing and Debriefing Audit Tool
AHRQ Safety Program for Surgery
Operating Room Briefing and Debriefing Audit Tool
Introduction
Problem Statement
One of the strongest determinants of safety culture is whether local and hospital leadership respond to staff patient safety concerns. Frontline providers unde…
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hcup-us.ahrq.gov/db/vars/tran_out/nisnote.jsp
September 01, 2008 - Healthcare Cost and Utilization Project (HCUP) NIS Notes
An official website of the Department of Health & Human Services
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Careers
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Espanol
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psnet.ahrq.gov/issue/use-beers-criteria-predict-adverse-drug-reactions-among-first-visit-elderly-outpatients
October 27, 2016 - Study
Use of the Beers criteria to predict adverse drug reactions among first-visit elderly outpatients.
Citation Text:
Chang C-M, Liu P-YY, Yang Y-HK, et al. Use of the Beers criteria to predict adverse drug reactions among first-visit elderly outpatients. Pharmacotherapy. 2005;25(6):…
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digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/flowchart
January 01, 2023 - Flowchart
Also Known As
Activity Diagram
Cross-Functional Flowchart
Process Flowchart
Process Map
"Swim Lane" Flowchart
Examples
Common Office Visit ( PDF , 34KB)
Flowchart Incoming Calls ( PDF , 432KB)
In-Office Prescribing Flowchart - Electronic System ( PDF , 475KB)
In-O…
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www.ahrq.gov/hai/tools/mrsa-prevention/surgery/4-es.html
April 01, 2025 - MRSA Prevention Toolkit: Targeting SSI
What Are the 4Es?
Previous Page Next Page
Table of Contents
MRSA Prevention Toolkit: Targeting SSI
The Four Key Strategies of MRSA Prevention: Targeting SSI
MRSA and SSI Prevention Phases
Importance of MRSA and SSI Prevention
MRSA Surveillance
The Evi…
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psnet.ahrq.gov/issue/high-performance-work-systems-health-care-management-part-1-and-part-2
March 22, 2017 - Special or Theme Issue
High-Performance Work Systems in Health Care Management: Parts 1-5.
Citation Text:
High-Performance Work Systems in Health Care Management: Parts 1-5. Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.
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hcup-us.ahrq.gov/db/vars/tran_out/kidnote.jsp
September 01, 2008 - Healthcare Cost and Utilization Project (HCUP) KID Notes
An official website of the Department of Health & Human Services
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Careers
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Espanol
FAQs…
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psnet.ahrq.gov/issue/iv-push-medications-survey-results-part-1-and-part-2
December 12, 2018 - Newspaper/Magazine Article
IV push medications survey results—part 1 and part 2.
Citation Text:
IV push medications survey results—part 1 and part 2. ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/fitzmaurice-da-et-al
January 01, 2023 - Fitzmaurice DA et al. 1996 "Evaluation of computerized decision support for oral anticoagulation management based in primary care."
Reference
Fitzmaurice DA, Hobbs FDR, Murray ET, et al. Evaluation of computerized decision support for oral anticoagulation management based in primary care. Br J Gen Pra…