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AHRQ: Agency for Healthcare Research and Quality

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  1. The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm. | PSNet

    psnet.ahrq.gov/issue/new-electronic-health-records-unknown-queue-caused-multiple-events-patient-harm
    October 12, 2022 - Book/Report The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm. Citation Text: The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm. Washington, DC: VA Office of the Inspector General; July 14 2022. Report No. 22-011…

  2. Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020. | PSNet

    psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fy-2020
    September 10, 2014 - Book/Report Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020. Citation Text: Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020. Washington, DC: Veterans Affairs Office of Inspector General; August …

  3. Medication errors in the homes of children with chronic conditions. | PSNet

    psnet.ahrq.gov/issue/medication-errors-homes-children-chronic-conditions
    April 27, 2010 - Study Medication errors in the homes of children with chronic conditions. Citation Text: Walsh KE, Mazor KM, Stille CJ, et al. Medication errors in the homes of children with chronic conditions. Arch Dis Child. 2011;96(6):581-6. doi:10.1136/adc.2010.204479. Copy Citation Format: …

  4. Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus. | PSNet

    psnet.ahrq.gov/issue/electronic-health-record-modernization-caused-pharmacy-related-patient-safety-issues
    January 31, 2024 - Book/Report Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus. Citation Text: Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the …

  5. When the lights go down in the delivery room: lessons from a ransomware attack. | PSNet

    psnet.ahrq.gov/issue/when-lights-go-down-delivery-room-lessons-ransomware-attack
    September 02, 2020 - Commentary When the lights go down in the delivery room: lessons from a ransomware attack. Citation Text: Gabbay‐Benziv R, Ben‐Natan M, Roguin A, et al. When the lights go down in the delivery room: lessons from a ransomware attack. Int J Gynaecol Obstet. 2023;162(2):562-568. doi:10.1002…

  6. Quality of care and quality of life: balancing patient safety and physician burnout. | PSNet

    psnet.ahrq.gov/issue/quality-care-and-quality-life-balancing-patient-safety-and-physician-burnout
    September 27, 2023 - Commentary Quality of care and quality of life: balancing patient safety and physician burnout. Citation Text: Minkoff H, O'Brien J, Berkowitz R. Quality of care and quality of life: balancing patient safety and physician burnout. Obstet Gynecol. 2024;144(3):e50-e55. doi:10.1097/aog.0000…

  7. Assessing the excess costs of the in-hospital adverse events covered by the AHRQ's Patient Safety Indicators in Switzerland. | PSNet

    psnet.ahrq.gov/issue/assessing-excess-costs-hospital-adverse-events-covered-ahrqs-patient-safety-indicators
    January 10, 2024 - Study Assessing the excess costs of the in-hospital adverse events covered by the AHRQ's Patient Safety Indicators in Switzerland. Citation Text: Giese A, Khanam R, Nghiem S, et al. Assessing the excess costs of the in-hospital adverse events covered by the AHRQ’s Patient Safety Indicato…

  8. Action on patient safety can reduce health inequalities. | PSNet

    psnet.ahrq.gov/issue/action-patient-safety-can-reduce-health-inequalities
    February 05, 2020 - Commentary Action on patient safety can reduce health inequalities. Citation Text: Wade C, Malhotra AM, McGuire P, et al. Action on patient safety can reduce health inequalities. BMJ. 2022;376:e067090. doi:10.1136/bmj-2021-067090. Copy Citation Format: DOI Google Scholar Bi…

  9. Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. | PSNet

    psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system
    April 19, 2023 - Book/Report Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. Citation Text: Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. Washington, DC: Department of Vet…

  10. Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. | PSNet

    psnet.ahrq.gov/issue/influence-surgeon-behavior-trainee-willingness-speak-randomized-controlled-trial
    February 22, 2019 - Study Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. Citation Text: Salazar MJB, Minkoff H, Bayya J, et al. Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. J Am Coll Surg. 2014;219(5):1001-…

  11. What defines a high-performing health system: a systematic review. | PSNet

    psnet.ahrq.gov/issue/what-defines-high-performing-health-system-systematic-review
    August 17, 2022 - Review What defines a high-performing health system: a systematic review. Citation Text: Ahluwalia SC, Damberg CL, Silverman M, et al. What Defines a High-Performing Health Care Delivery System: A Systematic Review. Jt Comm J Qual Patient Saf. 2017;43(9):450-459. doi:10.1016/j.jcjq.2017.…

  12. Physician perspectives on addressing anti-Black racism. | PSNet

    psnet.ahrq.gov/issue/physician-perspectives-addressing-anti-black-racism
    July 26, 2023 - Study Physician perspectives on addressing anti-Black racism. Citation Text: Brown CE, Marshall AR, Cueva KL, et al. Physician perspectives on addressing anti-Black racism. JAMA Netw Open. 2024;7(1):e2352818. doi:10.1001/jamanetworkopen.2023.52818. Copy Citation Format: DOI…

  13. Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results. | PSNet

    psnet.ahrq.gov/issue/machine-learning-models-outperform-manual-result-review-identification-wrong-blood-tube
    May 13, 2020 - Study Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results. Citation Text: Farrell C‐JL, Giannoutsos J. Machine learning models outperform manual result review for the identification of wrong blood in…

  14. Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network. | PSNet

    psnet.ahrq.gov/issue/types-diagnostic-errors-reported-paediatric-emergency-providers-global-paediatric-emergency
    December 16, 2020 - Study Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network. Citation Text: Mahajan P, Grubenhoff JA, Cranford J, et al. Types of diagnostic errors reported by paediatric emergency providers in a global paediatric eme…

  15. The racial disparities in maternal mortality and impact of structural racism and implicit racial bias on pregnant Black women: a review of the literature. | PSNet

    psnet.ahrq.gov/issue/racial-disparities-maternal-mortality-and-impact-structural-racism-and-implicit-racial-bias
    July 13, 2009 - Review The racial disparities in maternal mortality and impact of structural racism and implicit racial bias on pregnant Black women: a review of the literature. Citation Text: Montalmant KE, Ettinger AK. The racial disparities in maternal mortality and impact of structural racism and im…

  16. A scoping review of communication tools applicable to patients and their primary care providers after discharge from hospital. | PSNet

    psnet.ahrq.gov/issue/scoping-review-communication-tools-applicable-patients-and-their-primary-care-providers-after
    December 15, 2021 - Review A scoping review of communication tools applicable to patients and their primary care providers after discharge from hospital. Citation Text: Spencer RA, Singh Punia H. A scoping review of communication tools applicable to patients and their primary care providers after discharge …

  17. Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence. | PSNet

    psnet.ahrq.gov/issue/strengthening-open-disclosure-after-incidents-maternity-care-realist-synthesis-international
    September 18, 2024 - Review Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence. Citation Text: Adams M, Hartley J, Sanford N, et al. Strengthening open disclosure after incidents in maternity care: a realist synthesis of international resea…

  18. Language proficiency and adverse events in US hospitals: a pilot study. | PSNet

    psnet.ahrq.gov/issue/language-proficiency-and-adverse-events-us-hospitals-pilot-study
    January 23, 2012 - Study Language proficiency and adverse events in US hospitals: a pilot study. Citation Text: Divi C, Koss RG, Schmaltz SP, et al. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19(2):60-67. doi:10.1093/intqhc/mzl069. Copy Citation…

  19. Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings: a scoping review and thematic analysis. | PSNet

    psnet.ahrq.gov/issue/health-professionals-experiences-whistleblowing-maternal-and-newborn-healthcare-settings
    November 02, 2010 - Review Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings: a scoping review and thematic analysis. Citation Text: Capper T, Ferguson B, Muurlink O. Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings…

  20. Association between cancer-specific adverse event triggers and mortality: a validation study. | PSNet

    psnet.ahrq.gov/issue/association-between-cancer-specific-adverse-event-triggers-and-mortality-validation-study
    January 29, 2020 - Study Association between cancer-specific adverse event triggers and mortality: a validation study. Citation Text: Weingart SN, Nelson J, Koethe B, et al. Association between cancer‐specific adverse event triggers and mortality: A validation study. Cancer Med. 2020;9(12):4447-4459. doi:1…
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