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psnet.ahrq.gov/node/44190/psn-pdf
June 03, 2015 - Minimizing medical mistakes: mother's mission to reduce
hospital errors.
June 3, 2015
Takahara D. KDVR. May 19, 2015.
https://psnet.ahrq.gov/issue/minimizing-medical-mistakes-mothers-mission-reduce-hospital-errors
Parents of children who experience harm in the course of medical care serve as advocates to drive saf…
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psnet.ahrq.gov/node/45832/psn-pdf
April 05, 2017 - Best Practices in Patient Safety: 2nd Global Ministerial
Summit on Patient Safety.
April 5, 2017
Federal Ministry of Health and World Health Organization: Bonn, Germany; March 2017.
https://psnet.ahrq.gov/issue/best-practices-patient-safety-2nd-global-ministerial-summit-patient-safety
This report summarizes a wide…
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www.ahrq.gov/news/newsroom/case-studies/impact-case-study-stories.html
December 01, 2019 - Tell Us How You've Used AHRQ Resources!
Add your story to AHRQ's Impact Case Studies Program! It's easy.
Have you used AHRQ research, products, or tools to make changes in clinical practice or policy? Did you improve patient outcomes using an AHRQ tool or resource? If so, we want to highlight your success! Le…
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psnet.ahrq.gov/node/44093/psn-pdf
April 29, 2015 - South Carolina medication error bill is dangerously off
target.
April 29, 2015
ISMP Medication Safety Alert! Acute Care Edition. April 9, 2015;20:1,4.
https://psnet.ahrq.gov/issue/south-carolina-medication-error-bill-dangerously-target
This newsletter article reports on issues related to a legislation, drafted in …
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psnet.ahrq.gov/node/43677/psn-pdf
November 19, 2014 - Reporting and Learning Systems for Medication Errors:
The Role of Pharmacovigilance Centres.
November 19, 2014
Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October
2014. ISBN: 9789241507943.
https://psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-err…
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psnet.ahrq.gov/node/43302/psn-pdf
August 21, 2014 - A medication-based trigger tool to identify adverse events
in pediatric anesthesiology.
August 21, 2014
Taghon T, Elsey N, Miler V, et al. A medication-based trigger tool to identify adverse events in pediatric
anesthesiology. Jt Comm J Qual Patient Saf. 2014;40(7):326-334.
https://psnet.ahrq.gov/issue/medication-…
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psnet.ahrq.gov/node/838254/psn-pdf
October 05, 2022 - Embedded bias: how medical records sow discrimination.
October 5, 2022
Tahir D. Kaiser Health News. September 26, 2022.
https://psnet.ahrq.gov/issue/embedded-bias-how-medical-records-sow-discrimination
Negative patient representations in medical records perpetuate stereotypes that can affect care over ti…
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psnet.ahrq.gov/node/45881/psn-pdf
March 15, 2017 - CE: nursing's evolving role in patient safety.
March 15, 2017
Kowalski SL, Anthony M. CE: Nursing's Evolving Role in Patient Safety. Am J Nurs. 2017;117(2):34-48.
doi:10.1097/01.NAJ.0000512274.79629.3c.
https://psnet.ahrq.gov/issue/ce-nursings-evolving-role-patient-safety
Nursing is a key component of patient care…
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psnet.ahrq.gov/node/73615/psn-pdf
August 18, 2021 - Ripped apart: medical misdiagnosis and malpractice.
August 18, 2021
Kast S, Gerr M, Black D, et al. “On the Record.” WYPR. August 3, 2021
https://psnet.ahrq.gov/issue/ripped-apart-medical-misdiagnosis-and-malpractice
Misdiagnosis is a persistent challenge for patients and families to navigate. This audio news …
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psnet.ahrq.gov/node/37734/psn-pdf
April 30, 2008 - Improving the quality of written prescriptions in a general
hospital: the influence of 10 years of serial audits and
targeted interventions.
April 30, 2008
Gommans J, McIntosh P, Bee S, et al. Improving the quality of written prescriptions in a general hospital:
the influence of 10 years of serial audits and targe…
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psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
July 10, 2024 - My previous experiences, I would say especially at the Sticht Center on Aging at Wake Forest University
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/implement/teamworknotes.docx
June 02, 2025 - Individuals are unique, and their experiences dictate how messages are created, shared, and understood
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
May 01, 2017 - Individuals are
unique, and their experiences dictate how
messages are created, shared, and
understood
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psnet.ahrq.gov/node/33804/psn-pdf
March 03, 2016 - My
previous experiences, I would say especially at the Sticht Center on Aging at Wake Forest University
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - A Seasonal Care Transition Failure
July 1, 2011
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
The Case
A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine
resident—for routine follow-up…
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psnet.ahrq.gov/web-mm/surprise-wire
July 15, 2020 - Surprise Wire
Citation Text:
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
July 01, 2012 - Spotlight Case July 2008
Spotlight Case
Not-So-Therapeutic Tap
*
*
Source and Credits
This presentation is based on the July 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeffrey H. Barsuk, MD, MS; Northwestern University Feinberg Scho…
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integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/collect-and-use-data-quality-improvement
August 01, 2025 - An official website of the Department of Health & Human Services
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cdsic.ahrq.gov/sites/default/files/2024-12/OY2_Final%20MO%20Workgroup%20Charter.pdf
January 01, 2024 - Measurement and Outcomes Workgroup: Charter – Option Year 2
Measurement and Outcomes
Workgroup: Charter – Option Year 2
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
www.ahrq.gov
Contract No: 75Q80120D00018
Prepared by:
NORC at the University…
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digital.ahrq.gov/ahrq-funded-projects/vizhome-context-based-health-information-needs-assessment-strategy
January 01, 2023 - vizHOME: A Context-Based Health Information Needs Assessment Strategy
Project Final Report ( PDF , 725.32 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent th…