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psnet.ahrq.gov/node/60894/psn-pdf
September 09, 2020 - Increased patient safety-related incidents following the
transition into Daylight Savings Time.
September 9, 2020
Kolla BP, Coombes BJ, Morgenthaler TI, et al. Increased patient safety-related incidents following the
transition into Daylight Savings Time. J Gen Intern Med. 2020;36(1):51-54. doi:10.1007/s11606-020-0…
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psnet.ahrq.gov/node/47002/psn-pdf
April 25, 2018 - Making Health Care Safer in Ambulatory Care Settings
and Long Term Care Facilities (R18).
April 25, 2018
Rockville, MD: Agency for Healthcare Research and Quality; April 10, 2018. PA-18-750.
https://psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care-
facilities-r18
Research …
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psnet.ahrq.gov/node/867097/psn-pdf
November 06, 2024 - Recommendations but no Action: Improving the
Effectiveness of Quality and Safety Recommendations in
Healthcare.
November 6, 2024
Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations
In Healthcare. Dorset, UK: Health Services Safety Investigations Body; September 2024.
h…
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psnet.ahrq.gov/node/50848/psn-pdf
January 29, 2020 - Deficiencies in Care Coordination and Facility Response
to a Patient Suicide at the Minneapolis VA Health Care
System, Minnesota.
January 29, 2020
Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 7, 2020. Report No.
19-00468-67.
https://psnet.ahrq.gov/issue/deficiencies-care-co…
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psnet.ahrq.gov/node/44664/psn-pdf
May 30, 2016 - Ventilator-related adverse events: a taxonomy and
findings from 3 incident reporting systems.
May 30, 2016
Pham JC, Williams TL, Sparnon EM, et al. Ventilator-Related Adverse Events: A Taxonomy and Findings
From 3 Incident Reporting Systems. Respir Care. 2016;61(5):621-31. doi:10.4187/respcare.04151.
https://psnet…
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psnet.ahrq.gov/node/837901/psn-pdf
August 24, 2022 - Trial and error: learning from malpractice claims in
childhood surgery.
August 24, 2022
Prieto JM, Falcone B, Greenberg P, et al. Trial and error: learning from malpractice claims in childhood
surgery. J Surg Res. 2022;279:84-88. doi:10.1016/j.jss.2022.05.033.
https://psnet.ahrq.gov/issue/trial-and-error-learning-…
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psnet.ahrq.gov/node/74102/psn-pdf
January 01, 2022 - Workforce planning and safe workload in sterile
compounding hospital pharmacy services.
November 24, 2021
Chaker A, Omair I, Mohamed WH, et al. Workforce planning and safe workload in sterile compounding
hospital pharmacy services. Am J Health Syst Pharm. 2022;79(3):187–192. doi:10.1093/ajhp/zxab379.
https://psnet…
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psnet.ahrq.gov/node/39088/psn-pdf
September 01, 2015 - Laboratory session to improve first-year pharmacy
students' knowledge and confidence concerning the
prevention of medication errors.
September 1, 2015
Kiersma ME, Darbishire PL, Plake KS, et al. Laboratory session to improve first-year pharmacy students'
knowledge and confidence concerning the prevention of medica…
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psnet.ahrq.gov/node/41423/psn-pdf
January 03, 2017 - Improving documentation of a beta-blocker quality
measure through an anesthesia information management
system and real-time notification of documentation
errors.
January 3, 2017
Nair BG, Peterson GN, Newman S-F, et al. Improving documentation of a beta-blocker quality measure
through an anesthesia information man…
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psnet.ahrq.gov/node/866728/psn-pdf
September 18, 2024 - ROI for a fall prevention intervention: invest a little, save a
lot.
September 18, 2024
Cooper AS. ROI for a fall prevention intervention: invest a little, save a lot. Nurs Adm Q. 2024;48(3):248-
252. doi:10.1097/naq.0000000000000647.
https://psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save…
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psnet.ahrq.gov/node/46047/psn-pdf
May 17, 2017 - Medicare failed to investigate suspicious infection cases
from 96 hospitals.
May 17, 2017
Jewett C. Kaiser Health News. May 9, 2017.
https://psnet.ahrq.gov/issue/medicare-failed-investigate-suspicious-infection-cases-96-hospitals
The Centers for Medicare and Medicaid Services decision to withhold payment for certa…
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psnet.ahrq.gov/node/43665/psn-pdf
November 20, 2015 - Patient safety education to change medical students'
attitudes and sense of responsibility.
November 20, 2015
Roh H, Park SJ, Kim T. Patient safety education to change medical students' attitudes and sense of
responsibility. Med Teach. 2015;37(10):908-14. doi:10.3109/0142159X.2014.970988.
https://psnet.ahrq.gov/is…
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www.ahrq.gov/sites/default/files/2024-01/oleary-report.pdf
January 01, 2024 - engagement strategies.13-20 Importantly, the overwhelming majority of prior research
studies have evaluated … mutually reinforcing components of a redesigned
clinical microsystem and should be implemented and evaluated
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0198-tables14-17.pdf
June 02, 2025 - Overuse of Computed Tomography Scans for the Evaluation of Children with a First Generalized Afebrile, Atraumatic Seizure: Tables 14-17
Table 14. Mean (Standard Deviation) Proportion in Racial Groups within Sampled ZIP Codes of Residence‡
Sampled Group
Description
American
Indian or
Alaska…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0198-tables1-9.pdf
June 02, 2025 - Overuse of Computed Tomography Scans for the Evaluation of Children with a First Generalized Afebrile, Atraumatic Seizure: Tables 1-9
Table 1 [=IMG1]: Codes to Identify Neuroimaging in Administrative Claims
Imaging Modality
Code Type
Codes
Computerized Tomography (CT) of
Brain/Head Revenue (UB-92) 350, …
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0198-tables11-13.pdf
June 02, 2025 - Overuse of Computed Tomography Scans for the Evaluation of Children with a First Generalized Afebrile, Atraumatic Seizure: Tables 11-13
Table 11[=IMG11]: Signs and Symptoms of Increased Intracranial Pressure or Herniation
GENERAL DIAGNOSIS
DIAGNOSIS DETAIL
ICD-9-CM
CODE
Pupillary function Anisocoria 379.4…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/nutrtp6.pdf
May 01, 2013 - Volume 6. Concordance Between the Findings of Epidemiological Studies and Randomized Trials in Nutrition: An Empirical Evaluation and Citation Analysis
Technical Review 17
Nutritional Research Series
Volume 6: Concordance Between the Findings
of Epidemiological Studies and Randomized Trials
in Nutrition: An…
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effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-participant-generated-registries-guide-3rd-ed-addendum-white-paper.pdf
February 01, 2018 - Research White Paper Patient- or Participant-Generated Registries Addendum Registries for Evaluating Patient Outcomes Third Edition
Research White Paper
Patient- or Participant-Generated Registries
Research White Paper
Patient- or Participant-Generated Registries
Addendum to Regis…
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effectivehealthcare.ahrq.gov/products/cancer-registry-pet/abstract
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effectivehealthcare.ahrq.gov/products/collections/evaluates-telehealth