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  1. Spotlight

    psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
    January 01, 2025 - Spotlight Spotlight Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations  1 Source and Credits This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Samantha Brown…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72911/psn-pdf
    March 15, 2021 - The Impact of Communication on Medication Errors March 15, 2021 Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors The Case   A 93-year-old man with a history of chronic systolic heart failure…

  3. Anesthesiology Control Tower: Feedback Alerts to Supplement Treatment (ACTFAST) - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r21hs024581-avidan-final-report-2020.pdf
    January 01, 2020 - Anesthesiology Control Tower: Feedback Alerts to Supplement Treatment (ACTFAST) - Final Report 1. TITLE PAGE Title: Anesthesiology Control Tower: Feedback Alerts to Supplement Treatment (ACTFAST) Principal Investigator: Michael Avidan, MBBCh Key Team Members: Arbi Ben Abdallah, PhD; Yixin Chen, PhD; Brad Fritz…

  4. Disposition of Comments_Comparative Effectiveness Review No. 260: Nutrition as Prevention for Improved Cancer Health Outcomes (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-260-improved-cancer-outcomes-disposition-comments.pdf
    May 22, 2023 - Disposition of Comments_Comparative Effectiveness Review No. 260: Nutrition as Prevention for Improved Cancer Health Outcomes Comparative Effectiveness Review Disposition of Comments Report Title: Nutrition as Prevention for Improved Cancer Health Outcomes Draft report available for public comment…

  5. Enhancing Hawaii Hospital Information Content: Hospital Engagement.

    hcup-us.ahrq.gov/datainnovations/clinicalcontentenhancementtoolkit/hi24.jsp
    July 01, 2016 - Enhancing Hawaii Hospital Information Content: Hospital Engagement. An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Esp…

  6. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers | PSNet

    psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
    January 07, 2022 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers Citation Text: Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

  7. Final Contract Report -- State and Regional Demonstrations in Health IT: Outline for Final Impact Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/state-regional-demonstration-hit-in-final-report.pdf
    July 01, 2015 - maintenance, and the software will need to respond to customers’ new requirements as they implement EHRs … maintenance, and the software will need to respond to customers’ new requirements as they implement EHRs

  8. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
    April 27, 2022 - Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care Downloadedfromhttp://journals.lww.com/journalpatientsafetybyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78=on04/27/2022 RE…

  9. Customizing Value-based Methods to Prioritize Implementation of Pharmacogenomic Clinical Decision Support for Learning Health Systems - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r21hs026544-devine-final-report-2022.pdf
    January 01, 2022 - test results.11-13 Clinical decision support (CDS) alerts, embedded in electronic health records (EHRs

  10. Telehealth and Behavioral Health Integration | The Academy

    integrationacademy.ahrq.gov/products/topic-briefs/telehealth
    February 01, 2025 - include: E-consultations between care team members Web and mobile-based electronic health records (EHRs

  11. Final Progress Report: Improving Medication Management Practices and Care Transitions Through Technology (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/feldman-report.pdf
    January 01, 2024 - However, one main tool used in EHRs is the medication database that checks for drug-to-drug interactions

  12. Final Progress Report: Improving Patient Safety by Reducing Medication Errors (pdf file)

    www.ahrq.gov/sites/default/files/2024-03/strom2-report.pdf
    January 01, 2024 - or Electronic Health Records (EHR) implementations found in only about 10% of US hospitals and with EHRs

  13. Health Information Technology Evaluation Toolkit: 2009 Update (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/health-information-technology-evaluation-toolkit-2009-update.pdf
    January 01, 2009 - Health Information Technology Evaluation Toolkit: 2009 Update Health Information Technology Eva lua tion Toolkit 2009 Update Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 www.ahrq.gov Contract No. 2…

  14. Comprehensive Information Technology Solution for Quality and Patient Safety - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/uc1hs015236-jose-final-report-2008.pdf
    January 01, 2008 - Edwards PJ, Moloney K, Sainfort F, Jacko JA, Jose J, Maximizing your investment in EHR: Utilizing EHRs

  15. Final Progress Report: Enhancing Stroke Prehospital and Emergency Evaluation and Delivery (pdf file)

    www.ahrq.gov/sites/default/files/2025-03/prabhakaran-holl-report.pdf
    January 01, 2025 - Final Progress Report: Enhancing Stroke Prehospital and Emergency Evaluation and Delivery 1. Title Page Project Title Enhancing Stroke Prehospital and Emergency Evaluation and Delivery MPIs Shyam Prabhakaran, MD, MS, and Jane L. Holl, MD, MPH Organization University of Chicago Dates of the Project 07/01/2018 - 04/30…

  16. Chapter 2. Determine Surgical Site Infection Rates (continued) | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/final-reports/ssi/ssi2a.html
    April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection Chapter 2. Determine Surgical Site Infection Rates (continued) Previous Page Next Page Table of Contents Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection Executive S…

  17. Slide 1

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/system/delivery-system-initiative/rodriguez/rodriguez.pptx
    June 02, 2025 - Slide 1 Implementing Team Approaches for Improving Diabetes Care in Health Centers Hector P. Rodriguez, PhD, MPH (hrod@berkeley.edu) UC Berkeley School of Public Health iCARE (Innovative Care Approaches through Research & Education) Acknowledgements Other Research Team Members (University of California and RA…

  18. Final Progress Report: Adaptation and Pilot Implementation of a Validated, Electronic Real-Time Clinical Decision Support Tool for the Care of Pneumonia Patients in 12 Utah Urgent Care Centers (pdf file)

    www.ahrq.gov/sites/default/files/2025-06/dean-report.pdf
    January 01, 2025 - Final Progress Report: Adaptation and Pilot Implementation of a Validated, Electronic Real-Time Clinical Decision Support Tool for the Care of Pneumonia Patients in 12 Utah Urgent Care Centers Adaptation and pilot implementation of a validated, electronic real-time clinical decision support tool for the care of pne…

  19. WebM&M: Case Studies | PSNet

    psnet.ahrq.gov/webmm-case-studies
    March 25, 2025 - WebM&M: Case Studies WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…

  20. Factors Contributing to Sustainment Outcomes in Four States (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/factors-contributing-sustainment.pdf
    August 31, 2015 - Factors Contributing to Sustainment Outcomes in Four States 1 Factors Contributing to Sustainment Outcomes in Four States This supplementary material contains brief case studies that examine key factors influencing decisions about sustaining elements of four states’ CHIPRA Quality Demonstration Grants. The …
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