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psnet.ahrq.gov/issue/scanning-out-medication-errors-ohio-valley-hospitals-automated-iv-system-provides-real-time
December 21, 2016 - Newspaper/Magazine Article
Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data.
Citation Text:
Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data. Carbas…
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psnet.ahrq.gov/issue/first-do-less-harm-confronting-inconvenient-problems-patient-safety
March 29, 2007 - Book/Report
First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety.
Citation Text:
First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety. Koppel R, Gordon S, ed. Ithaca, NY: Cornell University Press; 2012. ISBN: 9780801450778.
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psnet.ahrq.gov/issue/making-medical-devices-safer-home
July 31, 2013 - Fact Sheet/FAQs
Making Medical Devices Safer at Home.
Citation Text:
Making Medical Devices Safer at Home. Consumer Updates. Silver Spring, MD: US Food and Drug Administration; December 12, 2012.
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psnet.ahrq.gov/issue/be-active-member-your-health-care-team
April 08, 2020 - Government Resource
Be an Active Member of Your Health Care Team.
Citation Text:
Be an Active Member of Your Health Care Team. US Food and Drug Administration; FDA.
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effectivehealthcare.ahrq.gov/sites/default/files/mrsascreening_protocol_20110602.pdf
August 10, 2017 - Home | AHRQ Effective Health Care Program
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U.S. Department of Health & Human Services
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psnet.ahrq.gov/issue/too-many-abandon-second-victims-medical-errors
June 10, 2018 - Newspaper/Magazine Article
Too many abandon the "second victims" of medical errors.
Citation Text:
Too many abandon the "second victims" of medical errors. ISMP Medication Safety Alert! Acute care edition. July 14, 2011;16:1-3.
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psnet.ahrq.gov/issue/negligence-and-ais-human-users
November 16, 2022 - Commentary
Negligence and AI's human users.
Citation Text:
Negligence and AI's human users. Selbst AD. Boston U Law Rev. 2020;100:1315-1376.
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psnet.ahrq.gov/issue/tired-doctor-safe-doctor
August 24, 2022 - Newspaper/Magazine Article
Is a tired doctor a safe doctor?
Citation Text:
Is a tired doctor a safe doctor? Goldman B. "White Coat, Black Art." CBC Radio. October 31, 2014.
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psnet.ahrq.gov/issue/rapid-response-team-activation-patients-can-mitigate-errors
July 18, 2018 - Newspaper/Magazine Article
Rapid response team activation by patients can mitigate errors.
Citation Text:
Rapid response team activation by patients can mitigate errors. ISMP Medication Safety Alert! Acute care edition. June 1, 2006.
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psnet.ahrq.gov/issue/fail-safe-patient-id-matching-remains-just-out-reach
October 05, 2016 - Newspaper/Magazine Article
Fail-safe patient ID matching remains just out of reach.
Citation Text:
Fail-safe patient ID matching remains just out of reach. Arndt RZ. Mod Healthc. July 14, 2018.
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psnet.ahrq.gov/issue/why-hospitals-still-make-serious-medical-errors-and-how-they-are-trying-reduce-them
October 04, 2023 - Newspaper/Magazine Article
Why hospitals still make serious medical errors—and how they are trying to reduce them.
Citation Text:
Why hospitals still make serious medical errors—and how they are trying to reduce them. Landro L. Wall Street Journal. March 12, 2023.
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www.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
December 01, 2023 - Reviewing the Team's Performance: Debrief
Research has shown that teams that effectively debrief their own performance can improve their teamwork in real time. 1 , 2 , 3 , 4 Although it is often difficult to find time for such reviews in healthcare, TeamSTEPPS advocates for after-action reviews; TeamSTEPPS ch…
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www.ahrq.gov/news/newsroom/case-studies/ktcquips52.html
October 01, 2014 - Nebraska Critical Access Hospitals Improve Safety With AHRQ TeamSTEPPS®
Search All Impact Case Studies
December 2010
The University of Nebraska Medical Center (UNMC) customized the coaching strategies used in the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) curriculum fo…
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www.ahrq.gov/news/newsroom/case-studies/cquips0702.html
October 01, 2014 - University of Pittsburgh Uses AHRQ's Patient Safety Culture Survey to Help Improve Nursing Home Care
Search All Impact Case Studies
December 2006
The University of Pittsburgh School of Medicine adapted AHRQ's Hospital Survey on Patient Safety Culture to survey nursing home staff as part of ongoing researc…
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psnet.ahrq.gov/issue/sunday-story-when-hospitals-dont-say-sorry
June 21, 2023 - Audiovisual Presentation
The Sunday story: when hospitals don't say sorry.
Citation Text:
The Sunday story: when hospitals don't say sorry. Rascoe A, Gorenstein D. National Public Radio. January 21, 2024.
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www.ahrq.gov/talkingquality/resources/podcasts-webinars.html
December 01, 2022 - Presentations on Health Care Quality Reporting Topics
Plug-In & Multimedia Help
Podcasts
How Social Media Can Draw Visitors to a Quality Report
Barbara Lambiaso and Lauren Piccolo from Massachusetts Health Quality Partners (MHQP) talk about how MHQP uses social media to promote awareness and use of comp…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/sca-key-drive-diagram.pdf
June 02, 2025 - Sickle Cell Anemia Preventive Care Key Driver Diagram
Establish contact and messaging system with SCA
patients, families, providers, and health plans.
Customizable messaging types depending on patient
preference.
Develop care coordinator programs for SCA. Community
outreach to homes of noncompliant patients to as…
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www.ahrq.gov/hai/tools/mvp/sustainability/workplan.html
January 01, 2017 - Annual Sustainability Work Plan: Caring for Mechanically Ventilated Patients
AHRQ Safety Program for Mechanically Ventilated Patients
Year ______________ Hospital Name ____________________________________ Unit _______________________
This Sustainability Plan template is designed to help…
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psnet.ahrq.gov/issue/investigation-management-venous-thromboembolism-risk-patients-following-thrombolysis-acute
November 13, 2019 - Book/Report
Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke.
Citation Text:
Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke. Farnborough, UK; Healthcare…
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digital.ahrq.gov/sites/default/files/docs/page/2006RaynerGorman_051911comp.pdf
June 16, 2021 - Normalizing RxNorm: Experiences using medication information standards for data integration
Normalizing RxNorm:
Experiences using medication
information standards for data
integration
Nicolas B Rayner David Maier
Portland State University
Paul N Gorman Judith R Logan
Oregon Health & S…