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psnet.ahrq.gov/perspective/update-patient-engagement-safety
January 01, 2017 - Finally, the 2018 literature provides insight into the next iteration of patient engagement research,
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psnet.ahrq.gov/issue/confidential-physician-feedback-reports-designing-optimal-impact-performance
May 11, 2016 - Book/Report
Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance.
Citation Text:
Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance. McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Resear…
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psnet.ahrq.gov/issue/assessing-evidence-context-sensitive-effectiveness-and-safety-patient-safety-practices
July 27, 2018 - Book/Report
Assessing the Evidence for Context-Sensitive Effectiveness and Safety of Patient Safety Practices: Developing Criteria.
Citation Text:
Assessing the Evidence for Context-Sensitive Effectiveness and Safety of Patient Safety Practices: Developing Criteria. Shekelle PG, Pron…
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psnet.ahrq.gov/issue/safe-prescribing-educational-intervention-medical-students
September 24, 2010 - Study
Safe prescribing: an educational intervention for medical students.
Citation Text:
Garbutt J, DeFer TM, Highstein G, et al. Safe prescribing: an educational intervention for medical students. Teach Learn Med. 2006;18(3):244-50.
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psnet.ahrq.gov/issue/reducing-and-preventing-adverse-drug-events-decrease-hospital-costs
March 05, 2013 - Government Resource
Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs.
Citation Text:
Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs. Research in Action, Issue 1. Rockville, MD: Agency for Healthcare Research and Quality; March 2001. AHRQ …
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psnet.ahrq.gov/issue/report-mid-staffordshire-nhs-foundation-trust-public-inquiry
November 06, 2015 - Book/Report
Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry.
Citation Text:
Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry. Francis R. London, UK: The Stationary Office; 2013. ISBN: 9780102981469.
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Sav…
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psnet.ahrq.gov/issue/assessment-ahrq-patient-safety-initiative-focus-implementation-and-dissemination-evaluation
May 21, 2014 - Book/Report
Assessment of the AHRQ Patient Safety Initiative: Focus on Implementation and Dissemination Evaluation Report III.
Citation Text:
Assessment of the AHRQ Patient Safety Initiative: Focus on Implementation and Dissemination Evaluation Report III. Farley DO, Damberg CL, Ridgely …
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psnet.ahrq.gov/issue/maternal-and-infant-health-inequality-new-evidence-linked-administrative-data
August 23, 2017 - Book/Report
Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data.
Citation Text:
Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data. Kennedy-Moulton K, Miller S, Persson P, et al. Cambridge, MA: National Bureau of Econo…
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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - Finally, some individuals develop workarounds that are superior to existing procedures. … excessively large doses of medications rather than contacting the pharmacist or the physician.( 13 ) Finally … ( 9 ) Finally, successful organizations harness latent problem-solving power at the bottom of the organizational
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - Finally, some individuals develop workarounds that are superior to existing procedures. … excessively large doses of medications rather than contacting the pharmacist or the physician.( 13 ) Finally … ( 9 ) Finally, successful organizations harness latent problem-solving power at the bottom of the organizational
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psnet.ahrq.gov/web-mm/dropped-no
October 30, 2019 - The Dropped "No"
Citation Text:
Johnson AJ. The Dropped "No". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/49637/psn-pdf
October 01, 2011 - The Dropped "No"
October 1, 2011
Johnson AJ. The Dropped "No". PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropped-no
The Case
A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in
his legs. Because the leg swelling was somewhat more pronounced in his…
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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - "Superficial" Report Leads to "Deep" Problem
Citation Text:
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/issue/nature-severity-and-causes-medication-incidents-australian-community-pharmacy-incident
May 05, 2021 - Study
The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: the QUMwatch study.
Citation Text:
Adie K, Fois RA, McLachlan AJ, et al. The nature, severity and causes of medication incidents from an Australian community pha…
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psnet.ahrq.gov/issue/e-delphi-study-obtain-expert-consensus-level-risk-associated-preventable-e-prescribing-events
January 19, 2022 - Study
An e-Delphi study to obtain expert consensus on the level of risk associated with preventable e-prescribing events.
Citation Text:
Heed J, Klein S, Slee A, et al. An e‐Delphi study to obtain expert consensus on the level of risk associated with preventable e‐prescribing events. Br…
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psnet.ahrq.gov/node/33602/psn-pdf
March 15, 2025 - Finally, physicians are required to participate in some form of Continuing Medical Education
(CME) and
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psnet.ahrq.gov/issue/diagnostic-accuracy-large-language-model-pediatric-case-studies
May 25, 2016 - Study
Diagnostic accuracy of a large language model in pediatric case studies.
Citation Text:
Barile J, Margolis A, Cason G, et al. Diagnostic accuracy of a large language model in pediatric case studies. JAMA Pediatr. 2024;178(3):313-315. doi:10.1001/jamapediatrics.2023.5750.
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - Finally, EMS personnel may preemptively request a quality review if an unusual circumstance in a patient … Finally, you interact with the community at large by assisting in public relations efforts, public education … Finally, feedback from the hospitals is really important so that they know how their interventions changed
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psnet.ahrq.gov/issue/training-hospital-staff-respond-mass-casualty-incident-summary-evidence-reporttechnology
December 24, 2008 - Government Resource
Training of Hospital Staff To Respond to a Mass Casualty Incident. Summary, Evidence Report/Technology Assessment.
Citation Text:
Training of Hospital Staff To Respond to a Mass Casualty Incident. Summary, Evidence Report/Technology Assessment. Hsu EB, Jenckes MW, Cat…
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psnet.ahrq.gov/issue/national-healthcare-quality-and-disparities-report-chartbook-patient-safety-0
May 02, 2017 - Book/Report
National Healthcare Quality and Disparities Report Chartbook on Patient Safety.
Citation Text:
National Healthcare Quality and Disparities Report Chartbook on Patient Safety. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Pub. No. 23-0046.
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