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psnet.ahrq.gov/issue/facing-our-mistakes
September 23, 2020 - Commentary
Classic
Facing our mistakes.
Citation Text:
Hilfiker D. Facing our mistakes. N Engl J Med. 1984;310(2):118-22.
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psnet.ahrq.gov/issue/medication-errors-mental-healthcare-systematic-review
September 22, 2021 - Review
Medication errors in mental healthcare: a systematic review.
Citation Text:
Maidment ID, Lelliott P, Paton C. Medication errors in mental healthcare: a systematic review. Qual Saf Health Care. 2006;15(6):409-13.
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psnet.ahrq.gov/issue/pharmacist-physician-relationship-detection-ambulatory-medication-errors
September 30, 2020 - Study
The pharmacist-physician relationship in the detection of ambulatory medication errors.
Citation Text:
Brown A, Bailey JH, Lee J, et al. The pharmacist-physician relationship in the detection of ambulatory medication errors. Am J Med Sci. 2006;331(1):22-24.
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psnet.ahrq.gov/issue/public-comment-period-extended-strategies-improve-patient-safety-draft-report-congress-public
June 16, 2021 - Press Release/Announcement
Public comment period extended for strategies to improve patient safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine.
Citation Text:
Public comment period extended for strategies to improve patient safety: Draft Re…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool10_dc_checklist.docx
November 01, 2015 - Tool 10: Discharge Process Checklist
Tool 10: Discharge PROCESS Checklist
Purpose
Provide updated guidance to readmission reduction teams for updating discharge processes, based on Centers for Medicare & Medicaid Services (CMS) documents.
Description
This tool, adapted from the CMS Conditions of Participation (CO…
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psnet.ahrq.gov/issue/evaluating-safety-and-competency-bedside
November 16, 2022 - Commentary
Evaluating safety and competency at the bedside.
Citation Text:
Kaplan T, Pilcher J. Evaluating safety and competency at the bedside. J Nurses Staff Dev. 2011;27(4):187-90. doi:10.1097/NND.0b013e3182236634.
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psnet.ahrq.gov/issue/relationship-between-nurse-education-level-and-patient-safety-integrative-review
April 10, 2024 - Review
The relationship between nurse education level and patient safety: an integrative review.
Citation Text:
Ridley RT. The relationship between nurse education level and patient safety: an integrative review. J Nurs Educ. 2008;47(4):149-56.
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psnet.ahrq.gov/issue/aspen-parenteral-nutrition-safety-consensus-recommendations
June 12, 2018 - Commentary
ASPEN parenteral nutrition safety consensus recommendations.
Citation Text:
Ayers P, Adams S, Boullata JI, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations. JPEN J Parenter Enteral Nutr. 2014;38(3):296-333. doi:10.1177/0148607113511992.
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psnet.ahrq.gov/issue/can-electronic-clinical-documentation-help-prevent-diagnostic-errors
December 02, 2020 - Commentary
Can electronic clinical documentation help prevent diagnostic errors?
Citation Text:
Schiff G, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? New Engl J Med. 2010;362(12):1066-1069. doi:10.1056/NEJMp0911734.
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psnet.ahrq.gov/issue/team-structure-and-adverse-events-home-health-care
February 03, 2011 - Study
Team structure and adverse events in home health care.
Citation Text:
Feldman PH, Bridges J, Peng T. Team structure and adverse events in home health care. Med Care. 2007;45(6):553-61.
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psnet.ahrq.gov/issue/supporting-patient-safety-and-clinical-pharmacy-services-collaborative
February 08, 2023 - Commentary
Supporting the Patient Safety and Clinical Pharmacy Services Collaborative.
Citation Text:
Mitchell JR. Supporting the patient safety and clinical pharmacy services collaborative. Am J Health Syst Pharm. 2012;69(14):1246-50. doi:10.2146/ajhp110558.
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psnet.ahrq.gov/issue/preventable-adverse-events-infants-hospitalized-bronchiolitis
April 11, 2011 - Study
Preventable adverse events in infants hospitalized with bronchiolitis.
Citation Text:
McBride SC, Chiang VW, Goldmann DA, et al. Preventable adverse events in infants hospitalized with bronchiolitis. Pediatrics. 2005;116(3):603-608. doi:10.1542/peds.2004-2387.
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www.ahrq.gov/research/findings/nhqrdr/nhqdr23/app-b.html
December 01, 2023 - 2023 National Healthcare Quality and Disparities Report
Appendix B. Quality Trends and Disparities Tables
Appendix B contains data tables showing trends in quality for measures by topic (e.g., Access, Person-Centered Care), as well as single-year disparities information by demographic group (e.g., race, incom…
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psnet.ahrq.gov/issue/pain-management-and-prescription-opioid-related-harms-exploring-state-evidence-proceedings
July 05, 2008 - Meeting/Conference Proceedings
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.
Citation Text:
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Works…
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psnet.ahrq.gov/issue/medical-harm-historical-conceptual-and-ethical-dimensions-iatrogenic-illness
May 13, 2020 - Book/Report
Classic
Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness.
Citation Text:
Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness. Sharpe VA, Faden AI. Cambridge NY; Cambridge University…
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psnet.ahrq.gov/issue/interrelationship-isolation-precautions-and-adverse-events-acute-care-facility
September 24, 2010 - Study
The interrelationship of isolation precautions and adverse events in an acute care facility.
Citation Text:
Spence MR, McQuaid M. The interrelationship of isolation precautions and adverse events in an acute care facility. Am J Infect Control. 2011;39(2):154-155. doi:10.1016/j.aj…
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psnet.ahrq.gov/issue/mask-shortage-straps-pharmacists-who-need-them-keep-medicines-pure
August 02, 2023 - Newspaper/Magazine Article
Mask shortage straps pharmacists who need them to keep medicines pure.
Citation Text:
Mask shortage straps pharmacists who need them to keep medicines pure. Jewett C, Lupkin S. Health Shots. National Public Radio. March 20, 2020.
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/hoch-i-et-al-2003
January 01, 2003 - Hoch I et al. 2003 "Countrywide computer alerts to community physicians improve potassium testing in patients receiving diuretics."
Reference
Hoch I, Heymann AD, Kurman I, et al. Countrywide computer alerts to community physicians improve potassium testing in patients receiving diuretics. J Am Med Inf…
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psnet.ahrq.gov/issue/impact-hospital-accreditation-quality-improvement-healthcare-systematic-review
September 23, 2020 - Review
Impact of hospital accreditation on quality improvement in healthcare: a systematic review.
Citation Text:
Alhawajreh MJ, Paterson AS, Jackson WJ. Impact of hospital accreditation on quality improvement in healthcare: a systematic review. PLoS ONE. 2023;18(12):e0294180. doi:10.137…
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effectivehealthcare.ahrq.gov/sites/default/files/interventions-horizon-scan-high-impact-1306.pdf
June 01, 2013 - Coordinating Council for Comparative Effectiveness
Research, AHRQ is interested in innovations in drugs … health care sector, horizon
scanning pertains to identification of new (and new uses of existing) pharmaceuticals … For purposes of horizon scanning, AHRQ’s interests are broad and encompass drugs,
devices, procedures … Information is compiled for expert comment on topics at a granular
level (i.e., similar drugs in the … ingestible sensor (formerly known as an Ingestible Event Marker or IEM), affixed to
conventional pharmaceuticals