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psnet.ahrq.gov/issue/poor-medication-history-plus-slow-symptom-onset-delays-diagnosis
October 12, 2022 - Commentary
Poor medication history plus slow symptom onset delays a diagnosis.
Citation Text:
Poor medication history plus slow symptom onset delays a diagnosis. Wilkin T, Hale LS, Claiborne RA. JAAPA. October 2009;22:39-41.
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psnet.ahrq.gov/issue/losing-moment-understanding-interruptions-nurses-work
September 19, 2012 - Study
Losing the moment: understanding interruptions to nurses' work.
Citation Text:
Hall LMG, Pedersen C, Fairley L. Losing the moment: understanding interruptions to nurses' work. J Nurs Adm. 2010;40(4):169-176. doi:10.1097/NNA.0b013e3181d41162.
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psnet.ahrq.gov/issue/effectiveness-community-collaborative-eliminating-use-high-risk-abbreviations-written
May 25, 2010 - Study
Effectiveness of a community collaborative for eliminating the use of high-risk abbreviations written by physicians.
Citation Text:
Leonhardt KK, Botticelli J. Effectiveness of a Community Collaborative for Eliminating the Use of High-risk Abbreviations Written by Physicians. J P…
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www.ahrq.gov/news/newsroom/case-studies/cquips0606.html
October 01, 2014 - HealthSouth Rehabilitation Facilities Use AHRQ Survey to Identify Top Performers
Search All Impact Case Studies
April 2006
HealthSouth, one of the nation's largest health care providers, implemented AHRQ's Hospital Survey on Patient Safety Culture in June 2005. Over 11,000 questionnaires were mailed to em…
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psnet.ahrq.gov/issue/creating-culture-safety-emergency-department-value-teamwork-training
October 14, 2020 - Study
Creating a culture of safety in the emergency department: the value of teamwork training.
Citation Text:
Jones F, Podila P, Powers C. Creating a culture of safety in the emergency department: the value of teamwork training. J Nurs Adm. 2013;43(4):194-200. doi:10.1097/NNA.0b013e318…
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psnet.ahrq.gov/issue/public-health-notification-fda-vail-products-enclosed-bed-systems
December 16, 2020 - Press Release/Announcement
Public Health Notification from FDA: Vail Products Enclosed Bed Systems.
Citation Text:
Public Health Notification from FDA: Vail Products Enclosed Bed Systems. MedWatch Safety Alert. Rockville, MD: US Food and Drug Administration; December 4, 2007.
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psnet.ahrq.gov/issue/top-10-patient-safety-issues-what-more-can-we-do
May 08, 2013 - Commentary
Top 10 patient safety issues: what more can we do?
Citation Text:
Steelman VM, Graling PR. Top 10 patient safety issues: what more can we do? AORN J. 2013;97(6):679-98, quiz 699-701. doi:10.1016/j.aorn.2013.04.012.
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psnet.ahrq.gov/issue/lessons-learned-about-human-fallibility-system-design-and-justice-aftermath-fatal-medication
August 17, 2022 - Webinar
Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.
Citation Text:
Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error. Institute for Safe Medication Practic…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-culture-survey-brazil-actions.html
August 01, 2024 - Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study
Actions Based on Survey Results
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Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study
In…
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psnet.ahrq.gov/issue/2019-john-m-eisenberg-patient-safety-and-quality-awards
August 14, 2024 - Special or Theme Issue
The 2019 John M. Eisenberg Patient Safety and Quality Awards.
Citation Text:
The 2019 John M. Eisenberg Patient Safety and Quality Awards. Jt Comm J Qual Saf. 2020;46(7):PI-II:2020;371-399.
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psnet.ahrq.gov/issue/leaders-role-medical-device-safety
August 14, 2017 - Newspaper/Magazine Article
The leader's role in medical device safety.
Citation Text:
Federico F. The leader's role in medical device safety. Healthcare executives must ensure appropriate policies, procedures. Healthcare executive. 2013;28(3):82-5.
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psnet.ahrq.gov/issue/plan-quality-improve-patient-safety-point-care
February 01, 2017 - Review
Plan for quality to improve patient safety at the point of care.
Citation Text:
Ehrmeyer SS. Plan for Quality to Improve Patient Safety at the Point of Care. Ann Saudi Med. 2011;31(4). doi:10.4103/0256-4947.83203.
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psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-time-professional-action
June 01, 2004 - Commentary
Disclosing harmful medical errors to patients: a time for professional action.
Citation Text:
Gallagher TH, Levinson W. Disclosing Harmful Medical Errors to Patients. Arch Intern Med. 2005;165(16). doi:10.1001/archinte.165.16.1819.
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psnet.ahrq.gov/issue/some-health-workers-suffering-addiction-steal-drugs-meant-patients
October 28, 2020 - Audiovisual
Some health workers suffering from addiction steal drugs meant for patients.
Citation Text:
Some health workers suffering from addiction steal drugs meant for patients. Mann B. All Things Considered. National Public Radio. October 5, 2020.
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psnet.ahrq.gov/issue/increased-incidence-anesthetic-adverse-events-late-afternoon-surgeries
October 19, 2022 - Commentary
The increased incidence of anesthetic adverse events in late afternoon surgeries.
Citation Text:
Johnson J. The increased incidence of anesthetic adverse events in late afternoon surgeries. AORN J. 2008;88(1):79-87. doi:10.1016/j.aorn.2008.02.020.
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psnet.ahrq.gov/issue/observational-assessment-surgical-teamwork-feasibility-study
August 18, 2017 - Study
Observational assessment of surgical teamwork: a feasibility study.
Citation Text:
Undre S, Healey A, Darzi A, et al. Observational assessment of surgical teamwork: a feasibility study. World J Surg. 2006;30(10):1774-83.
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psnet.ahrq.gov/issue/pediatric-drug-labeling-improving-safety-and-efficacy-pediatric-therapies
January 24, 2024 - Study
Pediatric drug labeling: improving the safety and efficacy of pediatric therapies.
Citation Text:
Roberts R, Rodriguez W, Murphy D, et al. Pediatric Drug Labeling. JAMA. 2003;290(7). doi:10.1001/jama.290.7.905.
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psnet.ahrq.gov/issue/current-status-monitoring-medication-practice
May 28, 2015 - Commentary
Current status of the monitoring of medication practice.
Citation Text:
Cousins D. Current status of the monitoring of medication practice. Am J Health Syst Pharm. 2009;66(5 Suppl 3):S49-56. doi:10.2146/ajhp080605.
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digital.ahrq.gov/track-6-using-reporting-systems-safety-and-quality-improvement
January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state2.html
January 01, 2024 - Current State of Diagnostic Safety: Implications for Research, Practice, and Policy
2. Methods
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Table of Contents
Current State of Diagnostic Safety: Implications for Research, Practice, and Policy
1. Introduction
2. Methods
3. Results
4. Discussion
References
Appe…