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psnet.ahrq.gov/node/34730/psn-pdf
October 29, 2013 - Medication Errors. 2nd ed.
October 29, 2013
Cohen MR, ed. Washington DC: American Pharmacists Association; 2007.
https://psnet.ahrq.gov/issue/medication-errors-2nd-ed
Cohen, executive director of the Institute for Safe Medication Practices (ISMP), combined 25 years of
experience as a leader in medication safety wi…
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psnet.ahrq.gov/node/47546/psn-pdf
November 14, 2018 - Why doctors hate their computers.
November 14, 2018
Gawande A. New Yorker. November 12, 2018.
https://psnet.ahrq.gov/issue/why-doctors-hate-their-computers
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as
digitization becomes more widespread in health care. He elabo…
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psnet.ahrq.gov/node/866255/psn-pdf
July 10, 2024 - Cyberattack led to harrowing lapses at Ascension
hospitals, clinicians say.
July 10, 2024
Pradhan R, Wells K. KFF Health News and Morning Edition, Michigan Public Radio: June 19, 2024.
https://psnet.ahrq.gov/issue/cyberattack-led-harrowing-lapses-ascension-hospitals-clinicians-say
Cybersecurity is increasingly see…
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psnet.ahrq.gov/node/74836/psn-pdf
February 16, 2022 - Outcomes-based nurse staffing during times of crisis and
beyond.
February 16, 2022
Dempsey C, Batten P. Outcomes-based nurse staffing during times of crisis and beyond. J Nurs Adm.
2022;52(2):91-98. doi:10.1097/nna.0000000000001114.
https://psnet.ahrq.gov/issue/outcomes-based-nurse-staffing-during-times-crisis-and…
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psnet.ahrq.gov/node/867749/psn-pdf
March 12, 2025 - How unprofessional behaviours between healthcare staff
threaten patient care and safety.
March 12, 2025
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 30.
doi:10.1080/14737167.2025.2460518…
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psnet.ahrq.gov/node/40101/psn-pdf
January 17, 2012 - Lessons learned from implementation of a computerized
application for pending tests at hospital discharge.
January 17, 2012
Dalal A, Poon EG, Karson A, et al. Lessons learned from implementation of a computerized application for
pending tests at hospital discharge. J Hosp Med. 2011;6(1):16-21. doi:10.1002/jhm.794.
…
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psnet.ahrq.gov/node/44918/psn-pdf
April 13, 2016 - National Reporting and Learning System Research and
Development.
April 13, 2016
Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research
Centre; 2016.
https://psnet.ahrq.gov/issue/national-reporting-and-learning-system-research-and-development
Incident reporting has a…
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psnet.ahrq.gov/node/45188/psn-pdf
June 01, 2016 - Reporting and second-order problem solving can turn
short-term fixes into long-term remedies.
June 1, 2016
ISMP Medication Safety Alert! Acute Care Edition. May 19, 2016;21:1-4.
https://psnet.ahrq.gov/issue/reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long-
term-remedies
Workarounds are pr…
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psnet.ahrq.gov/node/837300/psn-pdf
June 01, 2022 - Surgery is in itself a risk factor for the patient.
June 1, 2022
Aranaz-Ostáriz V, Gea-Velázquez De Castro MT, López-Rodríguez-Arias F, et al. Surgery is in itself a risk
factor for the patient. Int J Environ Res Public Health. 2022;19(8):4761. doi:10.3390/ijerph19084761.
https://psnet.ahrq.gov/issue/surgery-itself…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/child-hcahps-ahrq-program.pdf
June 02, 2025 - Introducing the Child HCAHPS® Survey Database webcast-Ginsberg
WELCOME FROM AHRQ
Caren Ginsberg, PhD
Director, CAHPS & SOPS Programs
Center for Quality Improvement & Patient Safety, AHRQ
AHRQ and the CAHPS Program
• AHRQ is:
► A research and science-based agency of the US Department of Health
and Human Servi…
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www.ahrq.gov/sdm/index.html
Shared Decision Making
Professional Education and Training in Shared Decision Making
Programs to increase shared decision making skills
Implementation Tools and Resources…
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psnet.ahrq.gov/node/46936/psn-pdf
April 11, 2018 - You've detailed your last wishes, but doctors may not see
them.
April 11, 2018
Lamas D.
https://psnet.ahrq.gov/issue/youve-detailed-your-last-wishes-doctors-may-not-see-them
Advance care planning can affect patient safety if the information is unheeded, unavailable, or unread.
Reporting on a physician's experienc…
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psnet.ahrq.gov/node/44425/psn-pdf
February 24, 2016 - Dangerous doses.
February 24, 2016
Roe S, King K. Chicago Tribune. February 10–13, 2016.
https://psnet.ahrq.gov/issue/dangerous-doses
Drug interactions can be hazardous to patients, particularly when combined with risk factors such as age
and use of medications for chronic conditions. This series of news reports d…
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psnet.ahrq.gov/node/37993/psn-pdf
August 20, 2008 - Peer support: healthcare professionals supporting each
other after adverse medical events.
August 20, 2008
van Pelt F. Peer support: healthcare professionals supporting each other after adverse medical events.
Qual Saf Health Care. 2008;17(4):249-52. doi:10.1136/qshc.2007.025536.
https://psnet.ahrq.gov/issue/peer-…
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psnet.ahrq.gov/node/43620/psn-pdf
October 29, 2014 - Error in intensive care: psychological repercussions and
defense mechanisms among health professionals.
October 29, 2014
Laurent A, Aubert L, Chahraoui K, et al. Error in intensive care: psychological repercussions and defense
mechanisms among health professionals. Crit Care Med. 2014;42(11):2370-8.
doi:10.1097/CC…
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psnet.ahrq.gov/node/47843/psn-pdf
March 06, 2019 - Structural iatrogenesis—a 43-year-old man with "opioid
misuse."
March 6, 2019
Stonington S, Coffa D. Structural Iatrogenesis - A 43-Year-Old Man with "Opioid Misuse". N Engl J Med.
2019;380(8):701-704. doi:10.1056/NEJMp1811473.
https://psnet.ahrq.gov/issue/structural-iatrogenesis-43-year-old-man-opioid-misuse
The…
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psnet.ahrq.gov/node/34786/psn-pdf
March 28, 2005 - Errors in drug computations during newborn intensive
care.
March 28, 2005
Perlstein PH, Callison C, White M, et al. Errors in Drug Computations During Newborn Intensive Care. Arch
Pediatr Adolesc Med. 1979;133(4):376-379. doi:10.1001/archpedi.1979.02130040030006.
https://psnet.ahrq.gov/issue/errors-drug-computatio…
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psnet.ahrq.gov/node/44627/psn-pdf
May 30, 2016 - Exploring attitudes and opinions of pharmacists toward
delivering prescribing error feedback: a qualitative case
study using focus group interviews.
May 30, 2016
Lloyd M, Watmough SD, O'Brien S, et al. Exploring attitudes and opinions of pharmacists toward delivering
prescribing error feedback: A qualitative case …
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www.ahrq.gov/cahps/surveys-guidance/hp/about/survey-measures.html
September 01, 2020 - CAHPS Health Plan Survey 5.0 Measures
For more information: Patient Experience Measures from the CAHPS Health Plan Survey (PDF, 308 KB)
Getting Needed Care
Q9 Easy for respondent to get necessary care, tests, or treatment
Q18 Respondent got appointment with specialists as soon as needed
…
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effectivehealthcare.ahrq.gov/sites/default/files/cf_deliberativemethodswebinar_introduction.pdf
April 19, 2012 - Slide 1
Community Forum Community Forum
Agency for Healthcare Research and Quality
Community Forum
April 19, 2012
Using Deliberative Methods
to Engage the Public:
How to design and implement an effective
deliberative session
Community Forum Community Forum Community Forum
2
Purpose
…