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www.ahrq.gov/diagnostic-safety/resources/issue-briefs.html
July 01, 2025 - The papers fall under two types—either a "call to action" or a "state of the science."
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psnet.ahrq.gov/issue/sorry-still-hardest-word
June 16, 2014 - Newspaper/Magazine Article
'Sorry' is still the hardest word.
Citation Text:
'Sorry' is still the hardest word. Donaldson L.
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psnet.ahrq.gov/issue/medication-related-harm
August 14, 2024 - Journal Article
Study
Catching those who fall
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psnet.ahrq.gov/issue/medical-mystery-alcoholism-didnt-cause-mans-diabetes-and-cirrhosis
July 06, 2011 - Newspaper/Magazine Article
Medical mystery: alcoholism didn’t cause man’s diabetes and cirrhosis.
Citation Text:
Medical mystery: alcoholism didn’t cause man’s diabetes and cirrhosis. Boodman SG. Washington Post. June 13, 2011:E1.
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psnet.ahrq.gov/issue/insurers-stop-paying-care-linked-errors
January 18, 2023 - From the Same Author(s)
During in-flight emergencies, sometimes airlines’ medical kits fall
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psnet.ahrq.gov/issue/hospitals-own-errors
February 04, 2009 - Newspaper/Magazine Article
Hospitals own up to errors.
Citation Text:
Hospitals own up to errors. Landro L. Wall Street Journal. August 25, 2009:D1.
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psnet.ahrq.gov/issue/introduction-trigger-tools-identifying-adverse-events
January 08, 2020 - Multi-use Website
Introduction to Trigger Tools for Identifying Adverse Events.
Citation Text:
Introduction to Trigger Tools for Identifying Adverse Events. Institute for Healthcare Improvement; IHI
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psnet.ahrq.gov/issue/medication-errors-associated-documented-allergies
March 18, 2010 - Government Resource
Medication errors associated with documented allergies.
Citation Text:
Medication errors associated with documented allergies. PA-PSRS Patient Saf Advis. September 2008;5:75-80.
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psnet.ahrq.gov/issue/fixing-medication-reconciliation-breakdown
September 06, 2023 - Newspaper/Magazine Article
Fixing the medication reconciliation breakdown.
Citation Text:
Fixing the medication reconciliation breakdown. Starr D; West L.
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psnet.ahrq.gov/issue/joint-commission-international-center-patient-safety
November 27, 2018 - Multi-use Website
Joint Commission International Center for Patient Safety.
Citation Text:
Joint Commission International Center for Patient Safety. JCAHO, Joint Commission on Accreditation of Healthcare Organizations
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psnet.ahrq.gov/issue/why-learning-patient-safety-incidents-still-so-hard-sociocultural-perspective-learning
June 29, 2011 - Download Citation
Related Resources From the Same Author(s)
Detection and prevention
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psnet.ahrq.gov/issue/multicentre-study-develop-medication-safety-package-decreasing-inpatient-harm-omission-time
May 18, 2022 - March 4, 2011
View More
Related Resources
Nurses' harm prevention
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psnet.ahrq.gov/issue/medical-injuries-among-hospitalized-children
February 15, 2017 - Investigators used the Wisconsin Medical Injury Prevention Program (WMIPP) screening method to analyze
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psnet.ahrq.gov/issue/when-illegitimate-tasks-threaten-patient-safety-culture-cross-sectional-survey-tertiary
February 19, 2020 - April 27, 2022
Improving hospital safety culture for falls prevention through interdisciplinary
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psnet.ahrq.gov/issue/perceptions-hospital-electronic-health-record-ehr-training-support-and-patient-safety-staff
October 03, 2018 - October 11, 2023
Improving hospital safety culture for falls prevention through interdisciplinary
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-plan-b-transcript.doc
November 04, 2014 - We had seven hospitals that were implementing a CAUTI prevention program. … This is actually a CAUTI prevention guide to patient safety. … Do you have a project manager with dedicated time coordinate your CAUTI prevention activities? … prevention on that same unit? … This has to do in applying mindfulness to CAUTI prevention.
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/6L2obA88s86MoZDbWtMPTU
December 01, 2011 - Vitamin D With or Without Calcium Supplementation for Prevention of Cancer and Fractures: An Updated … Preventive Services Task Force
Vitamin D With or Without Calcium Supplementation for Prevention
of … These functions suggest a possible role of vitamin D in
cancer prevention. … effects of a single annual megadose
of vitamin D3 (500 000 IU, equivalent to approximately
1370 IU/d) on fall … and fracture outcomes in
community-dwelling elderly women with a history of
fall or fracture (31).
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/stroke-atrial-fibrillation_executive.pdf
August 01, 2013 - control, and prevention of thromboembolic
events. … Therapeutic Options for Stroke Prevention in AF
VKAs are highly effective for the prevention of stroke … function, Rebleeding risk [2 points], Hypertension
[uncontrolled], Anemia, Genetic factors, Excessive
fall … function, Re-bleeding risk (2 points),
Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall … function, Re-bleeding
risk (2 points), Hypertension
(uncontrolled), Anemia, Genetic
factors, Excessive fall
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psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys
January 17, 2012 - September 18, 2019
Root cause analysis and actions for the prevention of medical errors
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psnet.ahrq.gov/issue/harnessing-situ-simulation-identify-human-errors-and-latent-safety-threats-adult-tracheostomy
September 23, 2020 - August 31, 2022
Improving hospital safety culture for falls prevention through interdisciplinary