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psnet.ahrq.gov/issue/non-clinical-errors-using-voice-recognition-dictation-software-radiology-reports
December 29, 2014 - Study
Non-clinical errors using voice recognition dictation software for radiology reports: a retrospective audit.
Citation Text:
Chang CA, Strahan R, Jolley D. Non-clinical errors using voice recognition dictation software for radiology reports: a retrospective audit. J Digit Imaging. …
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psnet.ahrq.gov/issue/explaining-unexplainable-impact-physicians-attitude-towards-litigation-their-incident
March 26, 2014 - Study
Explaining the unexplainable—the impact of physicians' attitude towards litigation on their incident disclosure behaviour.
Citation Text:
Renkema E, Broekhuis MH, Ahaus K. Explaining the unexplainable - the impact of physicians' attitude towards litigation on their incident disclos…
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psnet.ahrq.gov/issue/current-pulse-can-production-system-reduce-medical-errors-health-care
September 09, 2011 - Commentary
Current pulse: can a production system reduce medical errors in health care?
Citation Text:
Printezis A, Gopalakrishnan M. Current pulse: can a production system reduce medical errors in health care? Qual Manag Health Care. 2007;16(3):226-238.
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psnet.ahrq.gov/issue/successful-remediation-patient-safety-incidents-tale-two-medication-errors
January 26, 2022 - Commentary
Successful remediation of patient safety incidents: a tale of two medication errors.
Citation Text:
Helmchen LA, Richards MR, McDonald TB. Successful remediation of patient safety incidents: a tale of two medication errors. Health Care Manage Rev. 2011;36(2):114-123. doi:10.10…
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psnet.ahrq.gov/issue/national-physician-survey-diagnostic-error-paediatrics
August 04, 2021 - Study
A national physician survey of diagnostic error in paediatrics.
Citation Text:
Perrem LM, Fanshawe TR, Sharif F, et al. A national physician survey of diagnostic error in paediatrics. Eur J Pediatr. 2016;175(10):1387-92. doi:10.1007/s00431-016-2772-0.
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psnet.ahrq.gov/issue/insensible-losses-when-medical-community-forgets-family
January 17, 2024 - Commentary
Insensible losses: when the medical community forgets the family.
Citation Text:
Elias P. Insensible losses: when the medical community forgets the family. Health Aff (Millwood). 2015;34(4):707-710. doi:10.1377/hlthaff.2014.0536.
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psnet.ahrq.gov/issue/role-continuous-quality-improvement-and-psychological-safety-predicting-work-arounds
July 31, 2008 - Study
The role of continuous quality improvement and psychological safety in predicting work-arounds.
Citation Text:
Halbesleben JRB, Rathert C. The role of continuous quality improvement and psychological safety in predicting work-arounds. Health Care Manage Rev. 2008;33(2):134-44. do…
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psnet.ahrq.gov/issue/competence-and-certification-registered-nurses-and-safety-patients-intensive-care-units
May 01, 2006 - Study
Competence and certification of registered nurses and safety of patients in intensive care units.
Citation Text:
Kendall-Gallagher D, Blegen MA. Competence and certification of registered nurses and safety of patients in intensive care units. Am J Crit Care. 2009;18(2):106-113; q…
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psnet.ahrq.gov/issue/nurses-response-parents-speaking-efforts-ensure-their-hospitalized-childs-safety-attribution
May 13, 2020 - Study
Nurses' response to parents' 'speaking-up' efforts to ensure their hospitalized child's safety: an attribution theory perspective.
Citation Text:
Bsharat S, Drach-Zahavy A. Nurses' response to parents' 'speaking-up' efforts to ensure their hospitalized child's safety: an attributio…
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psnet.ahrq.gov/issue/retrospective-review-crisis-events-diagnostic-radiology-analysis-frequency-demographics
February 17, 2017 - Study
A retrospective review of crisis events in diagnostic radiology: an analysis of frequency, demographics, etiologies, and outcomes.
Citation Text:
Tindel MS, Darby JM, Simmons RL. A retrospective review of crisis events in diagnostic radiology: an analysis of frequency, demographics…
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psnet.ahrq.gov/issue/risk-factors-patient-safety-minimally-invasive-surgery-versus-conventional-surgery
August 10, 2016 - Study
Risk factors in patient safety: minimally invasive surgery versus conventional surgery.
Citation Text:
Rodrigues SP, Wever AM, Dankelman J, et al. Risk factors in patient safety: minimally invasive surgery versus conventional surgery. Surg Endosc. 2012;26(2):350-6. doi:10.1007/s0…
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psnet.ahrq.gov/issue/publics-views-medical-error-massachusetts
January 30, 2019 - Book/Report
The Public's Views on Medical Error in Massachusetts.
Citation Text:
The Public's Views on Medical Error in Massachusetts. Boston, MA: Harvard School of Public Health; December 2014.
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psnet.ahrq.gov/issue/quality-and-safety-initiatives-future-practice-surgery-meeting-patient-demands-enhanced
August 04, 2021 - Commentary
Quality and safety initiatives in the future practice of surgery: meeting patient demands for enhanced professionalism.
Citation Text:
Russell TR. Quality and safety initiatives in the future practice of surgery: meeting patient demands for enhanced professionalism. Surg Tod…
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psnet.ahrq.gov/issue/cusp-stop-bsi-evaluating-relationship-between-central-line-associated-bloodstream-infection
January 30, 2013 - Study
On the CUSP: Stop BSI: evaluating the relationship between central line–associated bloodstream infection rate and patient safety climate profile.
Citation Text:
Weaver SJ, Weeks K, Pham JC, et al. On the CUSP: Stop BSI: evaluating the relationship between central line-associated bl…
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psnet.ahrq.gov/issue/how-unprofessional-behaviours-between-healthcare-staff-threaten-patient-care-and-safety
July 24, 2024 - Commentary
How unprofessional behaviours between healthcare staff threaten patient care and safety.
Citation Text:
Aunger J, Maben J, Westbrook JI. How unprofessional behaviours between healthcare staff threaten patient care and safety. Expert Rev Pharmacoecon Outcomes Res. 2025;Epub Jan…
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psnet.ahrq.gov/issue/developing-and-testing-health-care-safety-hotline-prototype-consumer-reporting-system-patient
October 26, 2016 - Book/Report
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final Report.
Citation Text:
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final R…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/6dqHx6xQGq9GUv92rZUf2q
August 01, 2022 - Statin Use for the Primary Prevention of Cardiovascular Disease in Adults
The USPSTF recognizes that clinical decisions involve more considerations
than evidence alone. Clinicians should understand the evidence but
individualize decision making to the specific patient or situation.
Clinician Summary of USP…
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www.ahrq.gov/news/newsroom/case-studies/202301.html
October 01, 2024 - Ohio Veterans’ Facility Relied on AHRQ Resource to Develop Diabetes Initiative
Search All Impact Case Studies
March 2023
The Dayton (Ohio) Veterans Affairs (VA) Medical Center facility has adopted AHRQ’s SHARE Approach as part of the U.S. Department of Veterans Affairs' national Hypoglycemic Safety Initia…
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digital.ahrq.gov/principal-investigator/fontaine-patricia
January 01, 2023 - Fontaine, Patricia
Using fuzzy set qualitative comparative analysis (fs/QCA) to explore the relationship between medical "homeness" and quality.
Citation
Marcus Thygeson N, Solberg LI, Asche SE, et al. Using fuzzy set qualitative comparative analysis (fs/QCA) to explore the re…
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psnet.ahrq.gov/issue/extent-nature-and-consequences-adverse-events-results-retrospective-casenote-review-large-nhs
March 03, 2011 - Study
Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital.
Citation Text:
Sari AB-A, Sheldon T, Cracknell A, et al. Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large…