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psnet.ahrq.gov/issue/patient-who-falls-its-always-trade
February 17, 2011 - Commentary
The patient who falls: "It's always a trade-off."
Citation Text:
Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off". JAMA. 2010;303(3):258-66. doi:10.1001/jama.2009.2024.
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psnet.ahrq.gov/issue/tune-and-time-out-toward-surgeon-led-prevention-never-events
July 24, 2024 - Study
Tune-in and time-out: toward surgeon-led prevention of "never" events.
Citation Text:
Jones N. Tune-In and Time-Out: Toward Surgeon-Led Prevention of "Never" Events. J Patient Saf. 2019;15(4):e36-e39. doi:10.1097/PTS.0000000000000259.
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psnet.ahrq.gov/issue/patient-safety-trauma-maximal-impact-management-errors-level-i-trauma-center
February 19, 2020 - Study
Patient safety in trauma: maximal impact management errors at a level I trauma center.
Citation Text:
Ivatury RR, Guilford K, Malhotra AK, et al. Patient safety in trauma: maximal impact management errors at a level I trauma center. J Trauma. 2008;64(2):265-270; discussion 270-27…
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psnet.ahrq.gov/issue/frequency-pediatric-medication-administration-errors-and-contributing-factors
November 16, 2022 - Study
Frequency of pediatric medication administration errors and contributing factors.
Citation Text:
Ozkan S, Kocaman G, Ozturk C, et al. Frequency of pediatric medication administration errors and contributing factors. J Nurs Care Qual. 2011;26(2):136-43. doi:10.1097/NCQ.0b013e31820…
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psnet.ahrq.gov/issue/why-do-gdps-fail-recognise-oral-cancer-argument-oral-cancer-checklist
March 13, 2024 - Commentary
Why do GDPs fail to recognise oral cancer? The argument for an oral cancer checklist.
Citation Text:
Dave B. Why do GDPs fail to recognise oral cancer? The argument for an oral cancer checklist. Br Dent J. 2013;214(5):223-5. doi:10.1038/sj.bdj.2013.214.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_3_Physician_HO_508.pdf
January 01, 2010 - Strategy 4: IDEA Discharge Planning (Tool 3)
Guide to Patient and Family Engagement :: 1
Improving Discharge Outcomes with Patients and Families
Evidence for engaging patients
and families in discharge planning
Nearly 20 percent of patients experience an adverse
event within 30 days of discharge.1,2 Re…
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psnet.ahrq.gov/issue/communication-errors-radiology-pitfalls-and-how-avoid-them
September 24, 2017 - Review
Communication errors in radiology—pitfalls and how to avoid them.
Citation Text:
Waite S, Scott JM, Drexler I, et al. Communication errors in radiology - Pitfalls and how to avoid them. Clin Imaging. 2018;51:266-272. doi:10.1016/j.clinimag.2018.05.025.
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psnet.ahrq.gov/issue/bedside-detection-awareness-vegetative-state-cohort-study
December 16, 2020 - Study
Bedside detection of awareness in the vegetative state: a cohort study.
Citation Text:
Cruse D, Chennu S, Chatelle C, et al. Bedside detection of awareness in the vegetative state: a cohort study. Lancet. 2011;378(9809):2088-94. doi:10.1016/S0140-6736(11)61224-5.
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www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/rule.html
May 01, 2023 - Tool: Two-Challenge Rule
The Two-Challenge Rule is another tool used to facilitate team members' speaking up. It was developed to manage conflict when team members’ perception of a situation differs. Human factor experts developed the rule to help airline captains prevent disasters when otherwise excellent deci…
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psnet.ahrq.gov/issue/its-always-something-hospital-nurses-managing-risk
September 29, 2017 - Study
It's always something: hospital nurses managing risk.
Citation Text:
Groves PS, Finfgeld-Connett D, Wakefield BJ. It's always something: hospital nurses managing risk. Clin Nurs Res. 2014;23(3):296-313. doi:10.1177/1054773812468755.
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psnet.ahrq.gov/issue/structured-communication-patient-safety-emergency-medical-services-legal-case-report
November 21, 2021 - Commentary
Structured communication for patient safety in emergency medical services: a legal case report.
Citation Text:
Greenwood MJ, Heninger JR. Structured communication for patient safety in emergency medical services: a legal case report. Prehosp Emerg Care. 2010;14(3):345-8. doi…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-webinar-jan-2017-rybowski.pdf
January 01, 2017 - CAHPS Elicitation Protocol Webcast
Implementation of the
CAHPS Elicitation Protocol
Lise Rybowski
The Severyn Group
www.ahrq.gov/cahps
Two Options for Administration
• As part of the Clinician & Group Survey
• To take advantage of the sampling frame for the survey
• To facilitate linking of narrative respons…
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psnet.ahrq.gov/issue/applying-human-centered-design-thinking-enhance-safety-or
May 25, 2016 - Commentary
Applying human-centered design thinking to enhance safety in the OR.
Citation Text:
Criscitelli T, Goodwin W. Applying Human-Centered Design Thinking to Enhance Safety in the OR. AORN J. 2017;105(4):408-412. doi:10.1016/j.aorn.2017.02.004.
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www.ahrq.gov/sitemap.html
September 15, 2025 - AHRQ Main Site
Topics
Priority Populations
About Priority Populations
Children/Adolescents
Elderly
Low-Income
Racial/Ethnic Minorities
Rural/Inner-City Residents
Special Healthcare Needs
Women
Information in Spanish
Programs
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/tmpufJqkzbptG4uBtSGnam
September 01, 2022 - Screening for Syphilis Infection in Nonpregnant Adolescents and Adults
Clinician Summary of USPSTF Recommendation
Screening for Syphilis Infection in Nonpregnant
Adolescents and Adults September 2022
What does the USPSTF recommend?
A
Grade
…
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psnet.ahrq.gov/issue/recurring-call-action-every-healthcare-organization-needs-medication-safety-officer
March 03, 2021 - Newspaper/Magazine Article
A recurring call to action: every healthcare organization needs a medication safety officer!
Citation Text:
A recurring call to action: every healthcare organization needs a medication safety officer! ISMP Medication Safety Alert! Acute care edition. February…
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integrationacademy.ahrq.gov/news-and-events/news/engagement-and-retention-nonabstinent-patients-sud-treatment-new-asam-clinical
December 20, 2024 - An official website of the Department of Health & Human Services
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meps.ahrq.gov/mepsweb/survey_comp/household.jsp
December 02, 2022 - Medical Expenditure Panel Survey Household Component Overview
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psnet.ahrq.gov/issue/nil-os-orders-imaging-teachable-moment
November 13, 2024 - Commentary
Nil per os orders for imaging: a teachable moment.
Citation Text:
Wickerham AL, Schultz EJ, Lewine EB. Nil per Os Orders for Imaging: A Teachable Moment. JAMA Intern Med. 2017;177(11):1670-1671. doi:10.1001/jamainternmed.2017.3943.
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/WJE2r5v4CHc9dMZ4GT7dnT
Clinical Summary: Screening for HIV Infection
Clinical Summary: Screening for HIV Infection
Population Adolescents and adults aged 15 to 65 years Pregnant Persons
Recommendation
Screen for HIV infection.
Grade: A
Screen for HIV infection.
Grade: A
Risk Assessment
Although all adolesc…