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psnet.ahrq.gov/node/50720/psn-pdf
December 04, 2019 - Flu shot mix-up at Oklahoma facility leaves 10
hospitalized
December 4, 2019
The Associated Press. NBC News. November 8, 2019.
https://psnet.ahrq.gov/issue/flu-shot-mix-oklahoma-facility-leaves-10-hospitalized
Patients at residential care facilities are particularly vulnerable to harm from medication errors. This …
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psnet.ahrq.gov/node/35177/psn-pdf
June 23, 2009 - Narrativizing errors of care: critical incident reporting in
clinical practice.
June 23, 2009
Iedema R, Flabouris A, Grant S, et al. Narrativizing errors of care: critical incident reporting in clinical
practice. Soc Sci Med. 2006;62(1):134-44.
https://psnet.ahrq.gov/issue/narrativizing-errors-care-critical-incide…
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psnet.ahrq.gov/node/38528/psn-pdf
April 08, 2009 - Measurement of quality and assurance of safety in the
critically ill.
April 8, 2009
Pronovost P, Sexton B, Pham JC, et al. Measurement of quality and assurance of safety in the critically ill.
Clin Chest Med. 2009;30(1):169-79, x. doi:10.1016/j.ccm.2008.09.004.
https://psnet.ahrq.gov/issue/measurement-quality-and-…
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psnet.ahrq.gov/node/47594/psn-pdf
March 17, 2023 - Prevention of perioperative medication errors.
March 17, 2023
Nanji K. UpToDate. March 7, 2023.
https://psnet.ahrq.gov/issue/prevention-perioperative-medication-errors
Perioperative adverse drug events are common and understudied. This review examines factors that
contribute to adverse drug events in the surgical …
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www.ahrq.gov/nursing-home/resources/ensuring-safe-environment.html
April 01, 2022 - Ensuring a Safe Environment for Patients and Staff in COVID-19 Health-Care Facilities
Resource: Ensuring a safe environment for patients and staff in COVID-19 health-care facilities
This tool can be used to assess and monitor the structural capacities of facilities to (i) allow safe COVID‑19 case management…
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psnet.ahrq.gov/node/35214/psn-pdf
June 24, 2009 - Using clinical simulation to teach patient safety in an
acute/critical care nursing course.
June 24, 2009
Henneman EA, Cunningham H. Using clinical simulation to teach patient safety in an acute/critical care
nursing course. Nurse Educ. 2005;30(4):172-177.
https://psnet.ahrq.gov/issue/using-clinical-simulation-tea…
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psnet.ahrq.gov/node/867769/psn-pdf
March 12, 2025 - Lessons from Event Reports.
March 12, 2025
Lessons from Event Reports. Patient Safety Authority.
https://psnet.ahrq.gov/issue/lessons-event-reports
Small successes can inform and motivate actions leading to sustainable, evidence-based change. This
searchable collection of projects initiated in response to event re…
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digital.ahrq.gov/ahrq-funded-projects/development-and-evaluation-sociotechnical-metrics-inform-health-it-adaptation/citation/nurses
January 01, 2023 - Nurses' experience with health information technology: longitudinal qualitative study.
Citation
Zadvinskis IM, Garvey Smith J, Yen PY. Nurses' experience with health information technology: longitudinal qualitative study. JMIR Med Inform 2018 Jun 26;6(2):e38. PMID: 29945862.
Link
https://www.n…
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digital.ahrq.gov/ahrq-funded-projects/evaluating-prediction-tool-and-decision-aid-patients-crohns-disease/citation/risks-benefits-biologics-pediatric-inflammatory-bowel-disease
January 01, 2023 - Balancing and communicating the risks and benefits of biologics in pediatric inflammatory bowel disease.
Citation
Dulai PS, Siegel CA, Dubinsky MC. Balancing and communicating the risks and benefits of biologics in pediatric inflammatory bowel disease. Inflamm Bowel Dis 2013 Dec;19(13):2927-36.
…
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digital.ahrq.gov/organization/university-mississippi-medical-center
January 01, 2023 - University of Mississippi Medical Center
Detecting Med (Medication) Errors in Rural Hospitals Using Technology - 2008
Principal Investigator
Brown, Andrew
Project Name
Detecting Med (Medication) Errors in Rural Hospitals Using Technology
D…
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digital.ahrq.gov/program/national-center-excellence-primary-care-research-center-evidence-and-practice-improvement
January 01, 2023 - National Center for Excellence in Primary Care Research, Center for Evidence and Practice Improvement
Program Link: https://www.ahrq.gov/ncepcr/index.html
Assessing the Effects of EHR Optimization Interventions in Primary Care
Description
This research…
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digital.ahrq.gov/organization/childrens-healthcare-atlanta-inc
January 01, 2023 - Children's Healthcare of Atlanta, Inc.
Comprehensive Information Technology (IT) Solution for Quality and Patient Safety - 2009
Principal Investigator
Jose, Jim
Project Name
Comprehensive Information Technology (IT) Solution for Quality and Patient Safety
…
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digital.ahrq.gov/ahrq-funded-projects/evaluation-and-integration-automatic-fall-prediction-system/citation/tortuosity
January 01, 2023 - Tortuosity in movement pats is related to cognitive impairment: wireless Fractal estimation in assisted living facility.
Citation
Kearns WD, Nams VO, Fozard JL. Tortuosity in movement paths is related to cognitive impairment: wireless fractal estimation in assisted living facility residents. Methods I…
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digital.ahrq.gov/organization/lovelace-clinic-foundation
January 01, 2023 - Lovelace Clinic Foundation
New Mexico Health Info New Mexico Health Information Collaborative (NMHIC) - 2008
Principal Investigator
Gunter, Margaret
Project Name
New Mexico Health Information Collaborative (NMHIC)
New Mexico Health Informa…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/colon-cancer-gene-profiling_technical-brief.pdf
December 01, 2012 - GEP tests use defined protocols to evaluate the specimens to be analyzed: preparing
the RNA samples, … If a specific test were to be reviewed by the FDA, the review would evaluate
its safety and effectiveness … Tumor
marker utility grading system: a framework
to evaluate clinical utility of tumor markers.
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digital.ahrq.gov/sites/default/files/docs/page/findings-and-lessons-from-improving-management-of-individuals-with-complex-health-care-needs-through-health-it-grant-initiative.pdf
February 20, 2014 - Complex Healthcare
Needs Through Health IT Initiative
The MCP initiative was designed to identify and
evaluate
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www.ahrq.gov/sites/default/files/2024-01/thomas2-report.pdf
January 01, 2024 - Final Progress Report: Teamwork and Error in Neonatal Intensive Care
Teamwork and Error in Neonatal Intensive
Care
Eric J. Thomas, MD, MPH
Robert L. Helmreich, PhD
J. Bryan Sexton, PhD
Gwen Sherwood, RN, PhD, FAAN
Robert Lasky, PhD
Thomas Kallarackal
Sharon Crandell, MD
Jennipher Mulhollem
Dates:…
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www.uspreventiveservicestaskforce.org/uspstf/document/modeling-study/cervical-cancer-screening
August 21, 2018 - recent history of abnormal results, consistent with current guidelines; sensitivity analysis was used to evaluate
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psnet.ahrq.gov/node/49454/psn-pdf
July 01, 2004 - The next phase of this program will be dedicated to the
use of the management guidelines to evaluate
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psnet.ahrq.gov/node/49618/psn-pdf
February 01, 2011 - maintenance-of-certification (MOC) programs that require
physicians to self-assess their knowledge, evaluate