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psnet.ahrq.gov/node/60321/psn-pdf
May 13, 2020 - Safely practicing in a new environment: a qualitative
study to inform physician onboarding practices.
May 13, 2020
Lagoo J, Berry WR, Henrich N, et al. Safely practicing in a new environment: a qualitative study to inform
physician onboarding practices. Jt Comm J Qual Patient Saf. 2020;46(6):314-320.
doi:10.1016/j…
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psnet.ahrq.gov/node/47286/psn-pdf
July 18, 2018 - ISMP National Vaccine Errors Reporting Program 2017
analysis—part 1 and part 2.
July 18, 2018
ISMP Medication Safety Alert! Acute Care Edition. June 14, 2018,23:1-5. June 28, 2018;23:1-4,6,7.
https://psnet.ahrq.gov/issue/ismp-national-vaccine-errors-reporting-program-2017-analysis-part-1-and-part-
2
Mistakes in t…
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psnet.ahrq.gov/node/866908/psn-pdf
October 09, 2024 - Risk factors for wrong-site surgery: a study of 1,166
reports of informed consent and schedule errors.
October 9, 2024
Taylor MA, Yonash RA. Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent
and schedule errors. Patient Safety. 2024;6(1):1-11. doi:10.33940/001c.117084.
https://psnet…
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psnet.ahrq.gov/node/46573/psn-pdf
November 07, 2018 - Effects of a multimodal program including simulation on
job strain among nurses working in intensive care units: a
randomized clinical trial.
November 7, 2018
Khamali RE, Mouaci A, Valera S, et al. Effects of a Multimodal Program Including Simulation on Job Strain
Among Nurses Working in Intensive Care Units: A Ra…
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psnet.ahrq.gov/node/38570/psn-pdf
April 22, 2009 - Factors influencing incident reporting in surgical care.
April 22, 2009
Kreckler S, Catchpole K, McCulloch P, et al. Factors influencing incident reporting in surgical care. Qual
Saf Health Care. 2009;18(2):116-20. doi:10.1136/qshc.2008.026534.
https://psnet.ahrq.gov/issue/factors-influencing-incident-reporting-sur…
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psnet.ahrq.gov/node/842764/psn-pdf
January 18, 2023 - Medication use evaluation of high-dose long-term opioid
de-prescribing in multiple Veterans Affairs medical
centers.
January 18, 2023
Barrett AK, Sandbrink F, Mardian A, et al. Medication use evaluation of high-dose long-term opioid de-
prescribing in multiple Veterans Affairs medical centers. J Gen Intern Med. 20…
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www.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
March 01, 2021 - AHRQ Quality and Safety Review System (QSRS)
Mission
AHRQ has developed and tested an improved patient safety surveillance system to replace the Medicare Patient Safety Monitoring System (MPSMS). The new system is known as the Quality and Safety Review System (QSRS). The QSRS relies on clinical information re…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology9.html
April 01, 2025 - Exploration of Foundational Terminology and Paradigms for Improving Diagnosis
Evolving Methods and the Future of Diagnostic Improvement
Previous Page Next Page
Table of Contents
Exploration of Foundational Terminology and Paradigms for Improving Diagnosis
Introduction
Perspectives on Diagnostic …
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www.ahrq.gov/teamstepps-program/curriculum/communication/tools/ipass.html
July 01, 2023 - Tool: I-PASS
I-PASS has become the preferred handoff tool for patient transitions in many organizations. It is an example of an evidence-based option for conducting a structured handoff. Your facility should determine a standard protocol for delivering handoffs and make it known to everyone.
Standard scrip…
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www.ahrq.gov/hai/tools/ambulatory-care/lab-testing-toolkit.html
January 01, 2018 - Improving Your Laboratory Testing Process
The tools in this step-by-step guide can increase the reliability of the testing process in your office by helping you examine how tests are managed.
A Step-by-Step Guide for Rapid-Cycle Patient Safety and Quality Improvement
About 40 percent of patient encounters i…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/clinical-pathway-methods-report.pdf
December 01, 2018 - treatment portions of Key Question
(KQ)3 and KQ4:
KQ3: What are the comparative effectiveness and harms … KQ4: What are the effectiveness and harms of other interventions? … cure (study-defined), complications,
symptom resolution (study-defined), CDI-related colectomy rate, harms … Recommendations
Guideline
Rating
Definition
A 1) Considerations for each recommendation (i.e., benefits and harms
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-report-improving-health-systems-access.pdf
August 01, 2019 - For the EtD framework, questions pertaining to EtD
elements (such as benefits/harms, outcome importance … characteristics
7
recommended for decision aids,”10 and includes information pertaining to harms … This additional information may include costs, harms,
subpopulations, summaries of organizational guidelines … systems
o Improve understanding and appropriate use of observational studies for effectiveness,
harms
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www.uspreventiveservicestaskforce.org/uspstf/document/c-reactive-protein-as-a-risk-factor-for-coronary-heart-disease-a-systematic-review-and-meta-analyses-for-the-us-preventive-services-task-force/coronary-heart-disease-screening-using-non-traditional-risk-factors-2009
July 15, 2008 - prevalence of the factor in the target population, the reliability and cost of the test, potential harms … To fully understand the balance of benefits and harms associated with any particular form of intensive … patients classified according to CRP levels, we also need to know the numbers needed to treat and the harms … The length of follow-up was inadequate to fully evaluate the potential harms of aggressive statin therapy
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/khUSqr94jqWPErt9ZRnQ95
October 01, 2009 - prevalence of the
factor in the target population, the reliability and cost of
the test, potential harms … To
fully understand the balance of benefits and harms associ-
ated with any particular form of intensive … patients classified according to CRP levels, we
also need to know the numbers needed to treat and the
harms … The length of
follow-up was inadequate to fully evaluate the potential
harms of aggressive statin therapy
-
effectivehealthcare.ahrq.gov/sites/default/files/c-difficile-update_disposition-comments.pdf
March 29, 2016 - We have added the
mortality outcomes for the studies
that reported CDI incidence to the
harms section … Peer Reviewer #1 Results KQ4, “Harms of Adjunctive Therapy,” there have
been a couple of case reports … Affiliation Section Comment Response
Peer Reviewer #6 Results For the antibiotic treatment section, the harms … We have added language
indicating that antimicrobial
resistance harms were not
assessed, Regarding
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/high-cholestorol-medications_disposition-comments.pdf
March 10, 2010 - As stated above, revised and reorganized
Results "harms and adherence" could include changes in mentation … Harms could include many other outcomes, but the scope of the
review required that a select few important … harms be considered for
confirmatory analyses undertaken in answering the posed questions
Source … which is likely to experience
different (degree, intensity and variety) drug associated efficacy and
harms
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/autism_executive.pdf
April 01, 2011 - In addition to
outcomes for treatment effectiveness, we extracted data
on harms/adverse effects.
4 … Long-term
outcomes include
quality of life,
social
integration, and
appropriate level
of independence
Harms … Harms data are also typically not reported in
nonmedical studies, although potential harms of
behavioral
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www.ahrq.gov/sites/default/files/2025-03/mcfarland-report.pdf
January 01, 2025 - Final Progress Report: Ambulatory Patient Safety of Clients in Treatment for Substance Abuse
TITLE PAGE
Title of Project: Ambulatory patient safety of clients in treatment for
substance abuse
Principal Investigator: Bentson McFarland, MD, PhD
Team Members: Colleen Lewy, PhD
Christina Nicolaidis, MD
Patri…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Desikan.pdf
March 01, 2002 - Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System
145
Reporting of Adverse Drug Events:
Examination of a Hospital Incident
Reporting System
Radhika Desikan, Melissa J. Krauss, W. Claiborne Dunagan,
Erin Christensen Rachmiel, Thomas Bailey, Victoria J. Fraser
Abstract
Ba…
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effectivehealthcare.ahrq.gov/products/nonopioid-chronic-pain/research