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  1. Appendix: State Overviews | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/tap.html
    October 01, 2014 - Designing and Implementing Medicaid Disease and Care Management Programs Appendix: State Overviews Previous Page Next Page Table of Contents Designing and Implementing Medicaid Disease and Care Management Programs Introduction Section 1: Planning a Care Management Program Section 2: Engaging S…

  2. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough | PSNet

    psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
    September 01, 2003 - SPOTLIGHT CASE Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough Citation Text: Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …

  3. A Loss of Trust and a Missed Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
    October 31, 2023 - SPOTLIGHT CASE A Loss of Trust and a Missed Diagnosis Citation Text: Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format:…

  4. Maternal Safety | PSNet

    psnet.ahrq.gov/primer/maternal-safety
    January 10, 2024 - Maternal Safety Citation Text: Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

  5. Retained Surgical Items: Causation and Prevention | PSNet

    psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
    January 04, 2024 - Retained Surgical Items: Causation and Prevention Citation Text: Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX End…

  6. 43-Pathway-Worksheet (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/43-pathway-worksheet.docx
    June 01, 2023 - Improving Surgical Care and Recovery Core and Surgery Specific Pathways Worksheet Use this worksheet to develop enhanced recovery pathways for use at your hospital. The information in this tool is based on evidence reviews (see appendix) conducted by the National Project Team at the American College of Surgeons and Jo…

  7. Case Example #5: WellMed | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-5.html
    July 01, 2019 - The team lead has MA training and helps with MA tasks such as maintaining daily flow logs, and ensuring

  8. Promoting Best Practice and Safety Through Preprinted Physician Orders (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Ehringer_17.pdf
    February 08, 2008 - Enforcement Managing changes in orders, keeping them current to reflect “best practice,” and ensuring

  9. Outcome Measure Harmonization and Data Infrastructure for Patient-Centered Outcomes Research in Depression: Final Report (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/outcome-research-white-paper.pdf
    June 01, 2022 - The work described in Chapter 2 focused on ensuring that the data elements necessary to calculate the … Registries should also prepare for data sharing activities by ensuring data are maintained appropriately … Registry pilot sites also experienced some burden in the form of ensuring the measures data were extracted

  10. Capturing essential information to achieve safe interoperability. | PSNet

    psnet.ahrq.gov/issue/capturing-essential-information-achieve-safe-interoperability
    February 23, 2015 - Commentary Capturing essential information to achieve safe interoperability. Citation Text: Weininger S, Jaffe MB, Rausch T, et al. Capturing Essential Information to Achieve Safe Interoperability. Anesth Analg. 2017;124(1):83-94. Copy Citation Format: Google Scholar PubMed…

  11. The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception towards Co-Design. | PSNet

    psnet.ahrq.gov/issue/patients-role-diagnostic-safety-and-excellence-passive-reception-towards-co-design
    April 10, 2019 - Book/Report The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception towards Co-Design. Citation Text: Epstein HM, Haskell H, Hemmelgarn C, et al. The Patient’s Role In Diagnostic Safety And Excellence: From Passive Reception Towards Co-Design. Rockville, MD: Agency…

  12. The WHO World Alliance for Patient Safety: a new challenge or an old one neglected? | PSNet

    psnet.ahrq.gov/issue/who-world-alliance-patient-safety-new-challenge-or-old-one-neglected
    February 14, 2024 - Commentary The WHO World Alliance for Patient Safety: a new challenge or an old one neglected? Citation Text: Edwards R. The WHO World Alliance for Patient Safety: a new challenge or an old one neglected? Drug Saf. 2005;28(5):379-86. Copy Citation Format: Google Scholar P…

  13. ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative. | PSNet

    psnet.ahrq.gov/issue/acgme-summary-report-pursuing-excellence-pathway-leaders-patient-safety-collaborative
    October 18, 2017 - Book/Report ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative. Citation Text: ACGME Summary Report: The Pursuing Excellence Pathway Leaders Patient Safety Collaborative. Passiment M, Wagner R, Weiss KB for the Pursuing Excellence in Clinical Learn…

  14. A Community Health Information Exchange-based Hospital Readmission Risk Prediction & Notification System | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/community-health-information-exchange-based-hospital-readmission-risk
    January 01, 2023 - A Community Health Information Exchange-based Hospital Readmission Risk Prediction & Notification System Project Final Report ( PDF , 250.21 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, …

  15. Relieving Anxiety in Children Undergoing Radiation Therapy Through Virtual Preparation | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/relieving-anxiety-children-undergoing-radiation-therapy-though-virtual-preparation
    January 01, 2023 - Relieving Anxiety in Children Undergoing Radiation Therapy Through Virtual Preparation Project Final Report ( PDF , 297.63 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessa…

  16. Patient involvement for improved patient safety: a qualitative study of nurses' perceptions and experiences. | PSNet

    psnet.ahrq.gov/issue/patient-involvement-improved-patient-safety-qualitative-study-nurses-perceptions-and
    July 19, 2019 - Study Patient involvement for improved patient safety: a qualitative study of nurses' perceptions and experiences. Citation Text: Skagerström J, Ericsson C, Nilsen P, et al. Patient involvement for improved patient safety: A qualitative study of nurses' perceptions and experiences. Nurs …

  17. Using nurses and office staff to report prescribing errors in primary care. | PSNet

    psnet.ahrq.gov/issue/using-nurses-and-office-staff-report-prescribing-errors-primary-care
    May 04, 2010 - Study Using nurses and office staff to report prescribing errors in primary care. Citation Text: Kennedy AG, Littenberg B, Senders JW. Using nurses and office staff to report prescribing errors in primary care. Int J Qual Health Care. 2008;20(4):238-45. doi:10.1093/intqhc/mzn015. Cop…

  18. Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update. | PSNet

    psnet.ahrq.gov/issue/quality-and-safety-considerations-intensity-modulated-radiation-therapy-astro-safety-white
    October 30, 2024 - Organizational Policy/Guidelines Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update. Citation Text: Moran JM, Bazan JG, Dawes SL, et al. Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety…

  19. Does the concept of safety culture help or hinder systems thinking in safety? | PSNet

    psnet.ahrq.gov/issue/does-concept-safety-culture-help-or-hinder-systems-thinking-safety
    October 12, 2011 - Commentary Does the concept of safety culture help or hinder systems thinking in safety? Citation Text: Reiman T, Rollenhagen C. Does the concept of safety culture help or hinder systems thinking in safety? Accid Anal Prev. 2014;68(July):5-15. doi:10.1016/j.aap.2013.10.033. Copy Citati…

  20. Cognitive biases in surgery: systematic review. | PSNet

    psnet.ahrq.gov/issue/cognitive-biases-surgery-systematic-review
    April 27, 2022 - Review Cognitive biases in surgery: systematic review. Citation Text: Armstrong BA, Dutescu IA, Tung A, et al. Cognitive biases in surgery: systematic review. Br J Surg. 2023;110(6):645-654. doi:10.1093/bjs/znad004. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3…
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