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psnet.ahrq.gov/node/74093/psn-pdf
November 17, 2021 - Prevent errors during emergency use of hypertonic
sodium chloride solutions.
November 17, 2021
ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.
https://psnet.ahrq.gov/issue/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions
Delays in diagnosis and treatment duri…
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psnet.ahrq.gov/node/47220/psn-pdf
September 12, 2018 - Strategically Advancing Patient and Family Advisory
Councils in New York State Hospitals.
September 12, 2018
Bethesda, MD: Institute for Patient- and Family-Centered Care; June 2018.
https://psnet.ahrq.gov/issue/strategically-advancing-patient-and-family-advisory-councils-new-york-state-
hospitals
Hospital patien…
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psnet.ahrq.gov/node/72807/psn-pdf
March 03, 2021 - Updated guidance needed for longstanding large volume
parenteral (LVP) labeling and packaging problems.
March 3, 2021
ISMP Medication Safety Alert! Acute care edition. February 11, 2021;26(3):1-4.
https://psnet.ahrq.gov/issue/updated-guidance-needed-longstanding-large-volume-parenteral-lvp-labeling-
and-packaging
…
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psnet.ahrq.gov/node/72585/psn-pdf
December 16, 2020 - Think health care workers are tested often for the
Coronavirus? Think again.
December 16, 2020
Wamsley L. National Public Radio and WBUR. December 7, 2020.
https://psnet.ahrq.gov/issue/think-health-care-workers-are-tested-often-coronavirus-think-again
Testing for COVID-19 is a core public safety strategy for …
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psnet.ahrq.gov/node/46069/psn-pdf
February 28, 2018 - Strategies for Creating, Sustaining, and Improving a
Culture of Safety in Health Care, Second Edition.
February 28, 2018
Joint Commission Resources. Oak Brook, IL: Joint Commission; 2017. ISBN: 9781599409474.
https://psnet.ahrq.gov/issue/strategies-creating-sustaining-and-improving-culture-safety-health-care-
seco…
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psnet.ahrq.gov/node/45324/psn-pdf
August 31, 2016 - The problem with medication reconciliation.
August 31, 2016
Pevnick JM, Shane R, Schnipper JL. The problem with medication reconciliation. BMJ Qual Saf.
2016;25(9):726-730. doi:10.1136/bmjqs-2015-004734.
https://psnet.ahrq.gov/issue/problem-medication-reconciliation
Medication reconciliation has demonstrated safet…
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psnet.ahrq.gov/node/34935/psn-pdf
June 23, 2009 - Improving patient care. The cognitive psychology of
missed diagnoses.
June 23, 2009
Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med.
2005;142(2):115-120.
https://psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
This case study de…
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psnet.ahrq.gov/node/40644/psn-pdf
October 04, 2020 - High-Performance Work Systems in Health Care
Management: Parts 1-5.
October 4, 2020
Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.
https://psnet.ahrq.gov/issue/high-performance-work-systems-health-care-management-part-1-and-part-2
In this continuing series, high-performance work pr…
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psnet.ahrq.gov/node/46512/psn-pdf
August 17, 2018 - The problem with using patient complaints for
improvement.
August 17, 2018
de Vos MS, Hamming JF, van de Mheen PJM-. The problem with using patient complaints for
improvement. BMJ Qual Saf. 2018;27(9):758-762. doi:10.1136/bmjqs-2017-007463.
https://psnet.ahrq.gov/issue/problem-using-patient-complaints-improvement
…
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psnet.ahrq.gov/node/838140/psn-pdf
November 07, 2015 - Safety-I, Safety-II and resilience engineering.
November 7, 2015
Patterson M, Deutsch ES. Safety-I, Safety-II and resilience engineering. Curr Probl Pediatr Adolesc Health
Care. 2015;45(12):382-389. doi:10.1016/j.cppeds.2015.10.001.
https://psnet.ahrq.gov/issue/safety-i-safety-ii-and-resilience-engineering
Organiz…
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www.ahrq.gov/pqmp/measures/thermal-condition.html
August 01, 2021 - Thermal condition of low birth weight neonates admitted to Level 2 or higher nurseries in the first 24 hours of life
Measure Domain: Management of Acute Conditions
Measure Sub-Domain: Temperatures of Low Birthweight Neonates
PQMP COE: CAPQuaM
Associated NQF # and Name: None
Products:
Fact Sheet (…
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psnet.ahrq.gov/node/46213/psn-pdf
June 28, 2017 - The second victim: a review.
June 28, 2017
Coughlan B, Powell D, Higgins MF. The Second Victim: a Review. Eur J Obstet Gynecol Reprod Biol.
2017;213:11-16. doi:10.1016/j.ejogrb.2017.04.002.
https://psnet.ahrq.gov/issue/second-victim-review
Maternity care is a high-risk environment. This review discusses second vic…
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psnet.ahrq.gov/node/44670/psn-pdf
January 23, 2017 - Shift-to-shift handoff effects on patient safety and
outcomes: a systematic review.
January 23, 2017
Mardis M, Davis JJ, Benningfield B, et al. Shift-to-Shift Handoff Effects on Patient Safety and Outcomes.
Am J Med Qual. 2017;32(1):34-42. doi:10.1177/1062860615612923.
https://psnet.ahrq.gov/issue/shift-shift-hand…
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psnet.ahrq.gov/node/34663/psn-pdf
December 23, 2008 - Improving the quality of health care: who will lead?
December 23, 2008
Becher EC, Chassin MR. Improving the quality of health care: who will lead? Health Aff (Millwood).
2001;20(5):164-79.
https://psnet.ahrq.gov/issue/improving-quality-health-care-who-will-lead
In this review, Becher and Chassin discuss the persis…
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digital.ahrq.gov/ahrq-funded-projects/use-electronic-personal-health-records-health-risk-reduction-discussion-tool/citation/uncovering
January 01, 2023 - Uncovering a role for electronic personal health records in reducing disparities in sexually transmitted infection rates among students at a predominantly African American university: mixed-methods study.
Citation
Jackman KM, Baral SD, Hightow-Weidman L, et al. Uncovering a role for electronic persona…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/osteoarthritis-knee-future_research.pdf
February 01, 2013 - We then
identified and discussed research design considerations for research needs. … outcome, timing, and setting) element(s), provided context, described related
ongoing research, and discussed … Because more than one research
design can be applied to an individual research need, we discussed the
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psnet.ahrq.gov/node/49810/psn-pdf
November 01, 2017 - has a
financial arrangement or other relationship with the manufacturers of any commercial products discussed
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psnet.ahrq.gov/node/49651/psn-pdf
May 01, 2012 - have a financial arrangement nor other relationship with the manufacturers of any
commercial products discussed
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cdsic.ahrq.gov/cdsic/AI-viewpoint
February 25, 2025 - The CDSiC Steering Committee has discussed several priority areas for the CDSiC to consider pursuing
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/updating-framework-protocol.pdf
September 06, 2023 - Notes will be reviewed and discussed by the investigators to evaluate how the
input provides insight