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psnet.ahrq.gov/node/43066/psn-pdf
December 10, 2014 - Reminder: pay attention to the appearance of your
medicines.
December 10, 2014
ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.
https://psnet.ahrq.gov/issue/reminder-pay-attention-appearance-your-medicines
This newsletter article describes an incident involving a patient who noticed that the tabl…
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psnet.ahrq.gov/node/46144/psn-pdf
June 28, 2017 - Reducing error in anticoagulant dosing via
multidisciplinary team rounding at point of care.
June 28, 2017
Sharma M, Krishnamurthy M, Snyder R, et al. Reducing error in anticoagulant dosing via multidisciplinary
team rounding at point of care. Clin Pract. 2017;7(2). doi:10.4081/cp.2017.953.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/41810/psn-pdf
January 31, 2018 - Toolkit for Reduction of Clostridium difficile Infections
Through Antimicrobial Stewardship.
January 31, 2018
Boston University School of Public Health. Rockville, MD: Agency for Healthcare Research and Quality;
September 2012. AHRQ Publication No. 120082EF.
https://psnet.ahrq.gov/issue/toolkit-reduction-clostridi…
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psnet.ahrq.gov/node/60567/psn-pdf
June 03, 2020 - Keeping Nursing Home Residents and Staff Safe in the
Era of COVID-19.
June 3, 2020
National Academy of Medicine. April-June 2020.
https://psnet.ahrq.gov/issue/keeping-nursing-home-residents-and-staff-safe-era-covid-19
Nursing homes are care environments that are particularly challenged by the COVID-19 pandemic. Th…
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psnet.ahrq.gov/node/47048/psn-pdf
April 22, 2023 - National Prescription Drug Take Back Day.
April 16, 2023
Drug Enforcement Administration. April 22, 2023.
https://psnet.ahrq.gov/issue/national-prescription-drug-take-back-day
Removing unused medications from the home can help prevent accidental exposure to unneeded
medications and limit their availability for mis…
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psnet.ahrq.gov/node/47540/psn-pdf
April 03, 2019 - Medication handling: towards a practical, human-centred
approach.
April 3, 2019
Marshall SD, Chrimes N. Medication handling: towards a practical, human-centred approach. Anaesthesia.
2019;74(3):280-284. doi:10.1111/anae.14482.
https://psnet.ahrq.gov/issue/medication-handling-towards-practical-human-centred-approac…
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psnet.ahrq.gov/node/41873/psn-pdf
November 28, 2012 - A new tool to give hospitalists feedback to improve
interprofessional teamwork and advance patient care.
November 28, 2012
Chesluk BJ, Bernabeo E, Hess B, et al. A new tool to give hospitalists feedback to improve
interprofessional teamwork and advance patient care. Health Aff (Millwood). 2012;31(11):2485-2492.
do…
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digital.ahrq.gov/principal-investigator/sharifi-mahnoos-h
January 01, 2023 - Sharifi, Mahnoos H.
Efficacy and unintended consequences of hard-stop alerts in electronic health record systems: a systematic review.
Citation
Powers EM, Shiffman RN, Melnick ER, et al. Efficacy and unintended consequences of hard-stop alerts in electronic health record syste…
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www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/evaluation-mental-health-apps.pdf
June 02, 2025 - AHRQ Report Proposes Framework To Assess Mental Health Apps
Function
Privacy and Security
Accessibility
Usability
Remote Monitoring
Costs
Risk and
Mitigation
Strategies
App Integrity
Risk Assessment
Evidence
Linkage to Care
Access to Crisis Care
Mental
Health
Features
Screening
Self Help
Planning
Social Inte…
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psnet.ahrq.gov/node/845305/psn-pdf
March 01, 2023 - An infrastructure to provide safer, higher quality, and
more equitable telehealth.
March 1, 2023
Kobeissi MM, Hickey JV. An infrastructure to provide safer, higher quality, and more equitable telehealth. Jt
Comm J Qual Patient Saf. 2023;49(4):213-222. doi:10.1016/j.jcjq.2023.01.006.
https://psnet.ahrq.gov/issue/in…
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psnet.ahrq.gov/node/44889/psn-pdf
April 13, 2017 - An organizational learning framework for patient safety.
April 13, 2017
Edwards MT. An Organizational Learning Framework for Patient Safety. Am J Med Qual. 2016;32(2):148-
155. doi:10.1177/1062860616632295.
https://psnet.ahrq.gov/issue/organizational-learning-framework-patient-safety
Organizations are encouraged t…
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cds.ahrq.gov/sites/default/files/AHRQ_Final_Report_2021.pdf
January 01, 2021 - AHRQ helps clinicians and their teams
advance a continuous stream of research
findings, clinical practice … Some components that were infrequently
updated were also removed or replaced,
which helps improve the … project, this enhancement gives insight into
the reach and performance of the project,
as well as helps
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digital.ahrq.gov/sites/default/files/docs/citation/cds-connect-year5-final-report-2021.pdf
January 01, 2021 - AHRQ helps clinicians and their teams
advance a continuous stream of research
findings, clinical practice … Some components that were infrequently
updated were also removed or replaced,
which helps improve the … project, this enhancement gives insight into
the reach and performance of the project,
as well as helps
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/heart-failure-transition-care_disposition-comments.pdf
May 27, 2014 - This review helps to identify the strength of available data in
support of these programs, in which … We have added an additional summary table
that helps readers quickly see when we found
evidence to … Rather, we hope
to provide information on efficacy that helps
stakeholders determine which strategy
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hospital/compare/WR_751_AHRQ_Quigley_08_26_10.pdf
April 01, 2010 - leadership
because, as members of the patient experience quality improvement committee have said,
“It helps
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psnet.ahrq.gov/node/49719/psn-pdf
September 01, 2014 - No BP During NIBP
September 1, 2014
Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/no-bp-during-nibp
The Case
An otherwise healthy 49-year-old man with atrial fibrillation was scheduled for ablation in the catheterization
laboratory under general endotracheal anes…
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psnet.ahrq.gov/node/50701/psn-pdf
November 26, 2019 - In Conversation With... Heidi Wald, MD
November 26, 2019
In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-heidi-wald-md
Editor’s note: Dr. Wald, MD, MSPH, is the Chief Quality and Safety Officer at SCL Health in Denver, CO.
She has previously served as …
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psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - Complaints as Safety Surveillance
September 1, 2016
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance
The Case
A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain
came on sudden…
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psnet.ahrq.gov/node/865658/psn-pdf
April 24, 2024 - Managing Care Challenges in a Group Home Setting: Is
Staffing Adequate for Unplanned Incidents?
April 24, 2024
Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for
Unplanned Incidents? PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/managing-care-challenges-group-…
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…