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psnet.ahrq.gov/issue/role-cognition-generating-and-mitigating-clinical-errors
January 07, 2015 - Review
Role of cognition in generating and mitigating clinical errors.
Citation Text:
Patel VL, Kannampallil TG, Shortliffe EH. Role of cognition in generating and mitigating clinical errors. BMJ Qual Saf. 2015;24(7):468-474. doi:10.1136/bmjqs-2014-003482.
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psnet.ahrq.gov/issue/nursing-2006-patient-safety-survey-report
March 01, 2023 - Study
Nursing 2006 Patient-safety survey report.
Citation Text:
Manno M, Hogan P, Heberlein V, et al. Nursing 2006. Patient-safety survey report. Nursing (Brux). 2006;36(5):54-64.
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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:…
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psnet.ahrq.gov/issue/cdc-grand-rounds-preventing-unsafe-injection-practices-us-health-care-system
February 27, 2019 - Government Resource
CDC Grand Rounds: preventing unsafe injection practices in the U.S. health-care system.
Citation Text:
Prevention C for DC and. CDC grand rounds: preventing unsafe injection practices in the U.S. health-care system. MMWR Morb Mortal Wkly Rep. 2013;62(21):423-5.
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psnet.ahrq.gov/issue/patient-safety-out-hours-primary-care-review-patient-records
June 16, 2021 - Study
Patient safety in out-of-hours primary care: a review of patient records.
Citation Text:
Smits M, Huibers L, Kerssemeijer B, et al. Patient safety in out-of-hours primary care: a review of patient records. BMC Health Serv Res. 2010;10:335. doi:10.1186/1472-6963-10-335.
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psnet.ahrq.gov/issue/leadership-improve-diagnosis-call-action
June 28, 2023 - Book/Report
Leadership To Improve Diagnosis: A Call to Action.
Citation Text:
Leadership To Improve Diagnosis: A Call to Action. Rosen M, Ali KJ, Buckley BO, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2021. AHRQ Publication No. 20(21)-0040-5-EF.
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/profiles/profile_song.pdf
August 09, 2025 - Understanding the Impacts of State Efforts to Increase Primary Care Spending
PI Name: Zirui Song, MD,
PhD
Grant Title: Evaluations of
Increasing State
Investments in Primary
Care: Effects on Health Care
Spending, Utilization, and
Quality
Organization Name:
Harvard Medical School
Gran…
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psnet.ahrq.gov/issue/when-health-care-moves-online-many-patients-are-left-behind
August 19, 2020 - Newspaper/Magazine Article
When health care moves online, many patients are left behind.
Citation Text:
Renault M. When health care moves online, many patients are left behind. Wired Online. 2020;(June 8, 2020).
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psnet.ahrq.gov/issue/checklist-improve-patient-safety-interventional-radiology
September 20, 2011 - Study
A checklist to improve patient safety in interventional radiology.
Citation Text:
Koetser ICJ, de Vries EN, van Delden OM, et al. A checklist to improve patient safety in interventional radiology. Cardiovasc Intervent Radiol. 2013;36(2):312-9. doi:10.1007/s00270-012-0395-z.
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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/indian-health-service-actions-needed-improve-use-data-adverse-events
September 07, 2016 - Book/Report
Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.
Citation Text:
Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. Washington, DC: United States Government Accounting Office; July 10, 2023. Publication GAO-23-1…
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psnet.ahrq.gov/issue/homecare-safety-virtual-quality-improvement-collaboratives
January 24, 2024 - Study
Homecare safety virtual quality improvement collaboratives
Citation Text:
Miller W, Asselbergs M, Bank J, et al. Homecare safety virtual quality improvement collaboratives. Healthc Q. 2020;22(SP). doi:10.12927/hcq.2020.26042.
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digital.ahrq.gov/ahrq-funded-projects/patient-centered-medical-home-information-model/annual-summary/2011
January 01, 2011 - Patient-Centered Medical Home Information Model - 2011
Project Name
Patient-Centered Medical Home Information Model
Principal Investigator
Waldren, Steven
Organization
Westat
Contract Number
290-09-00023I-6
Project Period
August 2010 - August 2011
AHRQ…
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psnet.ahrq.gov/issue/ensuring-competency-and-safety-when-onboarding-newly-hired-professional-staff
February 22, 2023 - Newspaper/Magazine Article
Ensuring competency and safety when onboarding newly hired professional staff.
Citation Text:
Ensuring competency and safety when onboarding newly hired professional staff. ISMP Medication Safety Alert! Acute care edition. April 20, 2023;28(8):1-4; May 4, 2023;…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/decision-models-guidance_methods.pdf
October 01, 2016 - modeling perspective determines the methods for choosing and handling consequences,
preferences, and, if examined … This applies both to the base case data and to the range of values examined in sensitivity
analyses … Counterintuitive model results (“paradoxical findings”) may indicate “bugs” or errors, so
such results should be examined
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www.ahrq.gov/sites/default/files/2024-05/schoenfeld-report.pdf
January 01, 2024 - Final Progress Report: Physician Perspectives Regarding the Use of Shared Decision Making in the Emergency Department
Title Page
Title: Physician Perspectives Regarding the Use of Shared Decision Making in the Emergency Department
PI: Elizabeth Schoenfeld, MD, MS
Team: Peter Lindenauer, MD, MSc, Kathleen Mazur, Ed…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mental-illness-heart_disposition-comments.pdf
April 22, 2013 - high rate of attrition, we rated the
study as being of good quality since the authors
thoroughly examined … We cite the articles and systematic reviews
examined for relevant studies in the Methods
section under … Conclusion Under Key Points for Key Question 3 (page ES-10,
page 40), it is noted that “no studies examined … particular) that were the
focus of this review but that were conducted in general
population samples examined
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/MWRHULpw6y_5Uk_KXTyvp8
January 10, 2017 - We searched for studies that examined the use of folic acid supple-
mentation with or without food fortification … We also searched for studies that
examined the supplementation of micronutrients (eg, multivita-
min, … line of no difference.36
Two of the cohort studies included in a previously published
meta-analysis26 examined … ratio for maternal report of wheezing at 1 year,
1.20 [95% CI, 1.04-1.39]).25 Three cohort studies examined … reported no significant findings in 38 reported associations
across these 3 studies.26
A meta-analysis examined
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/alarm-fatigue-1.pdf
March 01, 2020 - The studies in this
review examined alarm risk assessments as a component of larger quality improvement … outcome measures and provider perceptions, as well as barriers and facilitators to implementation, are
examined … The remaining 13 studies
examined the implementation of this PSP in a specific unit,
including the … percent, but the
percentage of unnecessary alarms remained consistent.4
Five additional studies examined … The remaining 10 studies examined establishing a multidisciplinary alarm management committee to
conduct
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/treatment-resistant-depression_disposition-comments.pdf
September 01, 2011 - Long-term durability of effect was then examined over the
subsequent six months. … In this study, cognitive function
was examined in a multisite, randomized controlled trial of TMS in … We specifically examined and found no
evidence of differences in outcome based age, and gender. … Specific
evidence of benefit or harm in medically comorbid subpopulations
was not examined in detail … submitted in January, 2009, using an
updated evidence base for TMS, Simpson and colleagues (2009)
examined