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psnet.ahrq.gov/issue/potentially-inappropriate-medication-use-among-elderly-home-care-patients-europe
September 19, 2016 - Study
Potentially inappropriate medication use among elderly home care patients in Europe.
Citation Text:
Fialová D, Topinková E, Gambassi G, et al. Potentially inappropriate medication use among elderly home care patients in Europe. JAMA. 2005;293(11):1348-58.
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psnet.ahrq.gov/issue/analysis-adverse-events-associated-adult-moderate-procedural-sedation-outside-operating-room
August 13, 2014 - Study
Analysis of adverse events associated with adult moderate procedural sedation outside the operating room.
Citation Text:
Karamnov S, Sarkisian N, Grammer R, et al. Analysis of Adverse Events Associated With Adult Moderate Procedural Sedation Outside the Operating Room. J Patient Sa…
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psnet.ahrq.gov/issue/communication-incidental-imaging-findings-inpatient-discharge-summaries-after-implementation
August 19, 2020 - Study
Communication of incidental imaging findings on inpatient discharge summaries after implementation of electronic health record notification system.
Citation Text:
Mattay G, Mallikarjun K, Grow P, et al. Communication of incidental imaging findings on inpatient discharge summaries a…
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digital.ahrq.gov/sites/default/files/docs/page/Dixie%20Baker1.ppt
June 16, 2021 - PowerPoint Presentation
Public Trust in Health Information: Foundational Principles for Dependable Systems
Dixie B. Baker, Ph.D.
Vice President for Technology
CTO, Enterprise and Infrastructure Solutions Group
Presented by Kathleen A. McCormick, Ph.D.
Senior Scientist/Vice President SAIC, Health Solutions
As Moder…
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psnet.ahrq.gov/issue/medication-reconciliation-during-hospitalization-and-hospital-home-interface-observational
June 16, 2021 - Study
Medication reconciliation during hospitalization and in hospital-home interface: an observational retrospective study.
Citation Text:
Volpi E, Giannelli A, Toccafondi G, et al. Medication reconciliation during hospitalization and in hospital-home interface: an observational retrosp…
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psnet.ahrq.gov/issue/improving-patients-intensive-care-admission-through-multidisciplinary-simulation-based-crisis
August 23, 2023 - Study
Improving patients' intensive care admission through multidisciplinary simulation-based crisis resource management: a qualitative study.
Citation Text:
Jensen JF, Ramos J, Ørom M‐L, et al. Improving patients' intensive care admission through multidisciplinary simulation‐based crisi…
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www.ahrq.gov/takeheart/training/implementing-automatic-referral/index.html
April 01, 2023 - Implementing Automatic Referral
This focus area will walk you through the necessary steps for implementing an automatic referral system in your hospital.
Automatic referral is a proven, evidence-based strategy to increase participation in cardiac rehabilitation (CR). Automatic referral is the systematic, au…
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www.ahrq.gov/teamstepps-program/curriculum/communication/tools/handoff.html
May 01, 2023 - Tool: Handoff
A handoff is a standardized method for transferring information, along with authority and responsibility, during transitions in patient care. Handoffs include the transfer of knowledge and information about the degree of uncertainty (uncertainty about diagnoses, etc.), response to treatment, recen…
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psnet.ahrq.gov/issue/impact-perioperative-catastrophes-anesthesiologists-results-national-survey
August 27, 2009 - Study
The impact of perioperative catastrophes on anesthesiologists: results of a national survey.
Citation Text:
Gazoni FM, Amato PE, Malik ZM, et al. The impact of perioperative catastrophes on anesthesiologists: results of a national survey. Anesth Analg. 2012;114(3):596-603. doi:10…
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psnet.ahrq.gov/issue/physician-mentorship-associated-occurrence-adverse-patient-safety-events
February 11, 2015 - Study
Is physician mentorship associated with the occurrence of adverse patient safety events?
Citation Text:
Harrison R, Sharma A, Lawton R, et al. Is Physician Mentorship Associated With the Occurrence of Adverse Patient Safety Events? J Patient Saf. 2021;17(8):e1633-e1637. doi:10.1097…
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psnet.ahrq.gov/issue/weekend-hospitalization-and-additional-risk-death-analysis-inpatient-data
September 23, 2015 - Study
Weekend hospitalization and additional risk of death: an analysis of inpatient data.
Citation Text:
Freemantle N, Richardson M, Wood J, et al. Weekend hospitalization and additional risk of death: An analysis of inpatient data. J R Soc Med. 2012;105(2). doi:10.1258/jrsm.2012.1200…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
April 01, 2016 - Purpose: To provide guidance to individuals who are conducting initial or followup disclosure conversations,
including key disclosure communication skills.
Who should use this tool? Disclosure Lead and any staff who will be engaged in disclosure conversations.
How to use this tool: Use Part I of the checklist to pre…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
August 01, 2022 - Disclosure Checklist
AHRQ Communication and Optimal Resolution Toolkit
Purpose: To provide guidance to individuals who are conducting initial or followup disclosure conversations, including key disclosure communication skills.
Who should use this tool? Disclosure Lead and any staff who will be engaged in …
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/menu.html
December 01, 2017 - On-Time Quality Improvement Program: On-Time Pressure Ulcer Prevention
Menu of Implementation Strategies
The On-Time Menu of Process Improvement Strategies for using reports is a list of potential ways facility teams may choose to integrate the pressure ulcer prevention reports into clinical practice. A menu …
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-3.html
September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science
Rationale for Improvement Tools
Previous Page Next Page
Table of Contents
The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immed…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight13supp.pdf
June 01, 2015 - Supplement to Evaluation Highlight No. 13
The National Evaluation of the
CHIPRA Quality Demonstration Grant Program
Evaluation Highlight No.13, June 2015
Supplement to Evaluation Highlight No. 13: How did CHIPRA
quality demonstration States employ learning collaboratives
to improve children’s health care quali…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/resources/resources.doc
June 02, 2025 - Resources
Resources
Contents
Federal Interagency Forum on Child and Family Statistics
Summary Health Statistics for U.S. Children
Advancing State Child Indicators Initiatives
This section identifies national initiatives that serve as clearinghouses for measures of the quality of children's health, health care, a…
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psnet.ahrq.gov/issue/assessing-relationship-between-patient-safety-culture-and-ehr-strategy
December 21, 2018 - Study
Assessing the relationship between patient safety culture and EHR strategy.
Citation Text:
Ford E, Silvera GA, Kazley AS, et al. Assessing the relationship between patient safety culture and EHR strategy. Int J Health Care Qual Assur. 2016;29(6):614-27. doi:10.1108/IJHCQA-10-2015-0…
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psnet.ahrq.gov/issue/evaluating-ambulatory-practice-safety-promises-project-administrators-and-practice-staff
August 14, 2017 - Study
Evaluating ambulatory practice safety: the PROMISES Project administrators and practice staff surveys.
Citation Text:
Singer SJ, Nieva HR, Brede N, et al. Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys. Med Care. 2015;53(2):141…
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psnet.ahrq.gov/issue/identifying-risks-areas-related-medication-administrations-text-mining-analysis-using-free
December 18, 2019 - Study
Identifying risks areas related to medication administrations - text mining analysis using free-text descriptions of incident reports.
Citation Text:
Härkänen M, Paananen J, Murrells T, et al. Identifying risks areas related to medication administrations - text mining analysis usin…