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psnet.ahrq.gov/issue/risk-evaluation-and-mitigation-strategy-rems-programs-and-medication-safety-parts-i-and-ii
March 15, 2022 - Special or Theme Issue
Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II.
Citation Text:
Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II. ISMP Medication Safety Alert! Acute care edition. July 13, 2…
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psnet.ahrq.gov/issue/medical-errors-education-prospective-study-new-educational-tool
March 20, 2024 - Study
Medical errors education: a prospective study of a new educational tool.
Citation Text:
Paxton JH, Rubinfeld IS. Medical errors education: A prospective study of a new educational tool. Am J Med Qual. 2010;25(2):135-42. doi:10.1177/1062860609353345.
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psnet.ahrq.gov/issue/literature-review-do-rapid-response-systems-reduce-incidence-major-adverse-events
April 22, 2015 - Review
Literature review: do rapid response systems reduce the incidence of major adverse events in the deteriorating ward patient?
Citation Text:
Massey D, Aitken LM, Chaboyer W. Literature review: do rapid response systems reduce the incidence of major adverse events in the deteriora…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND_0068_01-30-2009.pdf
January 01, 2009 - Effective Health Care
Topic Number(s): 0120
Document Completion Date: 6-8-09
1
Results of Topic Selection Process & Next Steps
Antinuclear autoantibody and rheumatoid factor testing in children will move forward to be refined as an
effectiveness review via the AHRQ Evidence-based Practice Ce…
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psnet.ahrq.gov/issue/safety-checklist-compliance-and-false-sense-safety-new-directions-research
December 29, 2014 - Commentary
Safety checklist compliance and a false sense of safety: new directions for research.
Citation Text:
Rydenfält C, Ek Å, Larsson PA. Safety checklist compliance and a false sense of safety: new directions for research. BMJ Qual Saf. 2014;23(3):183-6. doi:10.1136/bmjqs-2013-0021…
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psnet.ahrq.gov/issue/overcoming-human-barriers-safety-event-reporting-radiology
February 09, 2022 - Commentary
Overcoming human barriers to safety event reporting in radiology.
Citation Text:
Siewert B, Brook OR, Swedeen S, et al. Overcoming Human Barriers to Safety Event Reporting in Radiology. Radiographics. 2019;39(1):251-263. doi:10.1148/rg.2019180135.
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psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care-facilities-r18-0
January 11, 2023 - Grant Announcement
Making Health Care Safer in Ambulatory Care Settings and Long-term Care Facilities (R18).
Citation Text:
Making Health Care Safer in Ambulatory Care Settings and Long-term Care Facilities (R18). Rockville, MD: Agency for Healthcare Research and Quality; September 9, 20…
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psnet.ahrq.gov/issue/method-identify-pediatric-high-risk-diagnoses-missed-emergency-department
October 26, 2022 - Study
A method to identify pediatric high-risk diagnoses missed in the emergency department.
Citation Text:
Sundberg M, Perron CO, Kimia A, et al. A method to identify pediatric high-risk diagnoses missed in the emergency department. Diagnosis (Berl). 2018;5(2):63-69. doi:10.1515/dx-2018…
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psnet.ahrq.gov/issue/recurring-problem-retained-swabs-and-instruments
June 19, 2019 - Review
The recurring problem of retained swabs and instruments.
Citation Text:
Mahran MA, Toeima E, Morris EP. The recurring problem of retained swabs and instruments. Best Pract Res Clin Obstet Gynaecol. 2013;27(4):489-95. doi:10.1016/j.bpobgyn.2013.03.001.
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psnet.ahrq.gov/issue/state-art-review-speaking-healthcare
October 13, 2021 - Review
A state-of-the-art review of speaking up in healthcare.
Citation Text:
Violato E. A state-of-the-art review of speaking up in healthcare. Adv Health Sci Educ Theory Pract. 2022;27(4):1177-1194. doi:10.1007/s10459-022-10124-8.
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DOI Google Scholar …
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psnet.ahrq.gov/issue/studying-patient-safety-health-care-organizations-accentuate-qualitative
January 18, 2011 - Commentary
Studying patient safety in health care organizations: accentuate the qualitative.
Citation Text:
Hoff TJ, Sutcliffe K. Studying patient safety in health care organizations: accentuate the qualitative. Jt Comm J Qual Patient Saf. 2006;32(1):5-15.
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psnet.ahrq.gov/issue/medication-administration-time-study-mats-nursing-staff-performance-medication-administration
February 21, 2018 - Study
Medication Administration Time Study (MATS): nursing staff performance of medication administration.
Citation Text:
Elganzouri ES, Standish CA, Androwich I. Medication Administration Time Study (MATS): nursing staff performance of medication administration. J Nurs Admin. 2009;39(5)…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/putoolkit_module5_tools.docx
June 02, 2025 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 5 Tools
Action Plan Tool to Measure Pressure Ulcer Rates and Pressure Ulcer Prevention Practices
Tool 5C: Assessing Comprehensive Skin Assessment
Tool 5D: Assessing Standardized Risk Assessment
Tool 5E: Assessing Care Planning
AHRQ Pressure…
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digital.ahrq.gov/ahrq-funded-projects/human-factors-home-health-care/activity/human-factors-home-health-care/annual-summary/2010
January 01, 2010 - Human Factors in Home Health Care - 2010
Project Name
Human Factors in Home Health Care
Principal Investigator
O'Connell, Mary Ellen
Organization
National Research Council
Contract Number
AHR7128
Project Period
September 2009 – October 2011, Including No-Cos…
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digital.ahrq.gov/ahrq-funded-projects/human-factors-home-health-care/annual-summary/2011
January 01, 2011 - Human Factors in Home Health Care - 2011
Project Name
Human Factors in Home Health Care
Principal Investigator
O'Connell, Mary Ellen
Organization
National Research Council
Contract Number
AHR7128
Project Period
September 2009 - October 2011
AHRQ Fundin…
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digital.ahrq.gov/ahrq-funded-projects/reducing-disparities-health-care-quality-priority-populations-approach-focused/annual-summary/2010
January 01, 2010 - Reducing Disparities in Health Care Quality for Priority - 2010
Project Name
Reducing Disparities in Health Care Quality for Priority Populations: An Approach Focused on Improving Care in Under-resourced Settings Using Health IT and Other Quality Improvement Strategies
Principal Investigator…
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psnet.ahrq.gov/issue/safe-medication-prescribing-training-and-experience-medical-students-and-housestaff-large
December 22, 2008 - Study
Safe medication prescribing: training and experience of medical students and housestaff at a large teaching hospital.
Citation Text:
Garbutt J, Highstein G, Jeffe DB, et al. Safe medication prescribing: training and experience of medical students and housestaff at a large teachin…
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psnet.ahrq.gov/issue/death-inside-lemuel-shattuck-hospital-case-study-medical-treatment-persons-mental-health
May 03, 2023 - Book/Report
Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.
Citation Text:
Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities. Massachusetts Protection …
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psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps
February 24, 2011 - Study
Classic
Communication failures: an insidious contributor to medical mishaps.
Citation Text:
Sutcliffe K, Lewton E, Rosenthal M. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79(2):186-194.
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psnet.ahrq.gov/issue/delineation-risk-through-exploration-culture-safety-community-home-health
December 04, 2016 - Study
Delineation of risk through the exploration of a culture of safety in community home health.
Citation Text:
Stevenson L, McRae C, Mughal WA. Delineation of Risk Through the Exploration of a Culture of Safety in Community Home Health. Home Health Care Manag Pract. 2007;19(6). doi:…