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AHRQ: Agency for Healthcare Research and Quality

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  1. Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021. | PSNet

    psnet.ahrq.gov/issue/comprehensive-healthcare-inspection-summary-report-evaluation-care-coordination-veterans
    July 27, 2022 - Book/Report Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021. Citation Text: Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administra…

  2. Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia. | PSNet

    psnet.ahrq.gov/issue/care-and-oversight-deficiencies-related-multiple-homicides-louis-johnson-va-medical-center
    February 10, 2021 - Book/Report Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia. Citation Text: Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Vir…

  3. Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center. | PSNet

    psnet.ahrq.gov/issue/inadequate-emergency-department-care-and-physician-misconduct-washington-dc-va-medical-center
    September 30, 2020 - Book/Report Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center. Citation Text: Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center. Office of the Inspector General. Washington, DC: Departme…

  4. Simulation-based education to train learners to "speak up" in the clinical environment: results of a randomized trial. | PSNet

    psnet.ahrq.gov/issue/simulation-based-education-train-learners-speak-clinical-environment-results-randomized-trial
    September 27, 2023 - Study Simulation-based education to train learners to "speak up" in the clinical environment: results of a randomized trial. Citation Text: Oner C, Fisher N, Atallah F, et al. Simulation-Based Education to Train Learners to "Speak Up" in the Clinical Environment: Results of a Randomized …

  5. Advancing the next generation of handover research and practice with cognitive load theory. | PSNet

    psnet.ahrq.gov/issue/advancing-next-generation-handover-research-and-practice-cognitive-load-theory
    November 10, 2021 - Commentary Advancing the next generation of handover research and practice with cognitive load theory. Citation Text: Young JQ, Wachter R, Cate OT, et al. Advancing the next generation of handover research and practice with cognitive load theory. BMJ Qual Saf. 2016;25(2):66-70. doi:10.11…

  6. Patient safety climate in primary care: age matters. | PSNet

    psnet.ahrq.gov/issue/patient-safety-climate-primary-care-age-matters
    June 11, 2010 - Study Patient safety climate in primary care: age matters. Citation Text: Holden LM, Watts DD, Walker PH. Patient safety climate in primary care: age matters. J Patient Saf. 2009;5(1):23-28. doi:10.1097/PTS.0b013e318199d4bf. Copy Citation Format: DOI Google Scholar PubMed…

  7. Ensuring safe and equitable discharge: a quality improvement initiative for individuals with hypertensive disorders of pregnancy. | PSNet

    psnet.ahrq.gov/issue/ensuring-safe-and-equitable-discharge-quality-improvement-initiative-individuals-hypertensive
    October 19, 2022 - Study Ensuring safe and equitable discharge: a quality improvement initiative for individuals with hypertensive disorders of pregnancy. Citation Text: Zacherl KM, Sterrett EC, Hughes BL, et al. Ensuring safe and equitable discharge: a quality improvement initiative for individuals with h…

  8. Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors. | PSNet

    psnet.ahrq.gov/issue/unintentionally-retained-foreign-objects-descriptive-study-308-sentinel-events-and
    March 20, 2019 - Study Emerging Classic Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors. Citation Text: Steelman VM, Shaw C, Shine L, et al. Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentine…

  9. Health care worker perspectives of their motivation to reduce health care–associated infections. | PSNet

    psnet.ahrq.gov/issue/health-care-worker-perspectives-their-motivation-reduce-health-care-associated-infections
    June 02, 2019 - Study Health care worker perspectives of their motivation to reduce health care–associated infections. Citation Text: McClung L, Obasi C, Knobloch MJ, et al. Health care worker perspectives of their motivation to reduce health care-associated infections. Am J Infect Control. 2017;45(10):…

  10. A retrospective review of crisis events in diagnostic radiology: an analysis of frequency, demographics, etiologies, and outcomes. | PSNet

    psnet.ahrq.gov/issue/retrospective-review-crisis-events-diagnostic-radiology-analysis-frequency-demographics
    February 17, 2017 - Study A retrospective review of crisis events in diagnostic radiology: an analysis of frequency, demographics, etiologies, and outcomes. Citation Text: Tindel MS, Darby JM, Simmons RL. A retrospective review of crisis events in diagnostic radiology: an analysis of frequency, demographics…

  11. Pain as the neglected patient safety concern: five years on. | PSNet

    psnet.ahrq.gov/issue/pain-neglected-patient-safety-concern-five-years
    July 31, 2019 - Commentary Pain as the neglected patient safety concern: five years on. Citation Text: Twycross A, Forgeron P, Chorne J, et al. Pain as the neglected patient safety concern: Five years on. J Child Health Care. 2016;20(4):537-541. doi:10.1177/1367493516643422. Copy Citation Format: …

  12. Quality and the health system: becoming a high reliability organization. | PSNet

    psnet.ahrq.gov/issue/quality-and-health-system-becoming-high-reliability-organization
    November 16, 2022 - Review Quality and the health system: becoming a high reliability organization. Citation Text: Gaw M, Rosinia F, Diller T. Quality and the health system: becoming a high reliability organization. Anesthesiol Clin. 2018;36(2):217-226. doi:10.1016/j.anclin.2018.01.010. Copy Citation …

  13. Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. | PSNet

    psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fiscal-2021
    October 12, 2022 - Book/Report Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. Citation Text: Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. Washington, DC: Veterans Affairs Office of Inspector General; 2…

  14. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. | PSNet

    psnet.ahrq.gov/issue/how-when-and-why-bad-apples-spoil-barrel-negative-group-members-and-dysfunctional-groups
    August 08, 2018 - Commentary Classic How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Citation Text: Felps W, Mitchell TR, Byington E. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. …

  15. A new argument for no-fault compensation in health care: the introduction of artificial intelligence systems. | PSNet

    psnet.ahrq.gov/issue/new-argument-no-fault-compensation-health-care-introduction-artificial-intelligence-systems
    May 13, 2020 - Commentary A new argument for no-fault compensation in health care: the introduction of artificial intelligence systems. Citation Text: Holm S, Stanton C, Bartlett B. A new argument for no-fault compensation in health care: the introduction of artificial intelligence systems. Health Care…

  16. Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA. | PSNet

    psnet.ahrq.gov/issue/pathology-oversight-failures-veterans-health-care-system-ozarks-fayetteville-arkansas-va
    July 14, 2021 - Book/Report Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA. Citation Text: Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA. Office of Inspector General. June 2, 202…

  17. Language discordance and patient care-Babel. | PSNet

    psnet.ahrq.gov/issue/language-discordance-and-patient-care-babel
    October 30, 2024 - Commentary Language discordance and patient care-Babel. Citation Text: Huson TA. Language discordance and patient care-Babel. JAMA Intern Med. 2024;184(11):1287-1288. doi:10.1001/jamainternmed.2024.4273. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote…

  18. Semi-supervised classification of patient safety event reports. | PSNet

    psnet.ahrq.gov/issue/semi-supervised-classification-patient-safety-event-reports
    October 31, 2011 - Study Semi-supervised classification of patient safety event reports. Citation Text: McKnight SD. Semi-supervised classification of patient safety event reports. J Patient Saf. 2012;8(2):60-4. doi:10.1097/PTS.0b013e31824ab987. Copy Citation Format: DOI Google Scholar PubM…

  19. Guided reflection interventions show no effect on diagnostic accuracy in medical students. | PSNet

    psnet.ahrq.gov/issue/guided-reflection-interventions-show-no-effect-diagnostic-accuracy-medical-students
    September 20, 2016 - Study Guided reflection interventions show no effect on diagnostic accuracy in medical students. Citation Text: Lambe KA, Hevey D, Kelly BD. Guided Reflection Interventions Show No Effect on Diagnostic Accuracy in Medical Students. Front Psychol. 2018;9:2297. doi:10.3389/fpsyg.2018.02297…

  20. A call for safety: anticipating and mitigating risk across an obstetrics and gynecology service line. | PSNet

    psnet.ahrq.gov/issue/call-safety-anticipating-and-mitigating-risk-across-obstetrics-and-gynecology-service-line
    February 24, 2016 - Commentary A call for safety: anticipating and mitigating risk across an obstetrics and gynecology service line. Citation Text: Combs A, Klein VR. A call for safety: anticipating and mitigating risk across an obstetrics and gynecology service line. J Healthc Risk Manag. 2023;43(1):38-42.…
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