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psnet.ahrq.gov/node/37530/psn-pdf
December 15, 2008 - Do medical inpatients who report poor service quality
experience more adverse events and medical errors?
December 15, 2008
Taylor BB, Marcantonio ER, Pagovich O, et al. Do medical inpatients who report poor service quality
experience more adverse events and medical errors? Med Care. 2008;46(2):224-228.
doi:10.1097…
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psnet.ahrq.gov/node/845277/psn-pdf
March 01, 2023 - Risk assessment of the acute stroke diagnostic process
using failure modes, effects, and criticality analysis.
March 1, 2023
Liberman AL, Holl JL, Romo E, et al. Risk assessment of the acute stroke diagnostic process using failure
modes, effects, and criticality analysis. Acad Emerg Med. 2022;30(3):187-195. doi:10.…
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psnet.ahrq.gov/node/60228/psn-pdf
April 15, 2020 - How safety is compromised when hospital equipment is a
poor fit for patients who are obese.
April 15, 2020
Kukielka E. How safety is compromised when hospital equipment is a poor fit for patients who are obese.
Patient Saf J. 2020;2(1):48-56. doi:10.33940/data/2020.3.4.
https://psnet.ahrq.gov/issue/how-safety-comp…
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psnet.ahrq.gov/node/39800/psn-pdf
January 19, 2011 - Medication errors in paediatric outpatients.
January 19, 2011
Kaushal R, Goldmann DA, Keohane CA, et al. Medication errors in paediatric outpatients. BMJ Qual Saf.
2010;19(6). doi:10.1136/qshc.2008.031179.
https://psnet.ahrq.gov/issue/medication-errors-paediatric-outpatients
Pediatric medication errors are common …
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psnet.ahrq.gov/node/47787/psn-pdf
February 20, 2019 - How to be a very safe maternity unit: an ethnographic
study.
February 20, 2019
Liberati EG, Tarrant C, Willars J, et al. How to be a very safe maternity unit: An ethnographic study. Soc
Sci Med. 2019;223:64-72. doi:10.1016/j.socscimed.2019.01.035.
https://psnet.ahrq.gov/issue/how-be-very-safe-maternity-unit-ethnog…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0242-tables1-3.pdf
June 02, 2025 - Follow-up Visits for Children Who Are Obese or Overweight with a Weight-Related Comorbidity: Tables 1-3
Table 1. Documentation of Weight Addressed
Table 2: ICD-9 Codes for Weight-Related Comorbidities
Description Code
Diabetes 250.xx
Hyperlipidemia 272.0, 272.1, 272.2, 272.3, 272.4
Hypertension 401
…
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psnet.ahrq.gov/node/836953/psn-pdf
April 20, 2022 - Systems-level factors affecting registered nurses during
care of women in labor experiencing clinical deterioration.
April 20, 2022
Bernstein SL, Catchpole K, Kelechi TJ, et al. Systems-level factors affecting registered nurses during care
of women in labor experiencing clinical deterioration. Jt Comm J Qual Patien…
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psnet.ahrq.gov/node/60635/psn-pdf
January 01, 2021 - Systemic defenses to prevent intravenous medication
errors in hospitals: a systematic review.
July 1, 2020
Kuitunen SK, Niittynen I, Airaksinen M, et al. Systemic Defenses to Prevent Intravenous Medication Errors
in Hospitals. J Patient Saf. 2021;17(8):e1669-e1680. doi:10.1097/pts.0000000000000688.
https://psnet.a…
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www.ahrq.gov/patient-safety/reports/engage/next-steps.html
March 01, 2017 - Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
Next Steps
Previous Page Next Page
Table of Contents
Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
Executive Summary
Introduction
Limitations of the Env…
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psnet.ahrq.gov/node/45473/psn-pdf
April 24, 2018 - Navigating a ship with a broken compass: evaluating
standard algorithms to measure patient safety.
April 24, 2018
Hefner JL, Huerta T, McAlearney AS, et al. Navigating a ship with a broken compass: evaluating standard
algorithms to measure patient safety. J Am Med Inform Assoc. 2017;24(2):310-315.
doi:10.1093/jami…
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psnet.ahrq.gov/node/60185/psn-pdf
April 01, 2020 - Associations between stopping prescriptions for opioids,
length of opioid treatment, and overdose or suicide
deaths in US veterans: observational evaluation.
April 1, 2020
Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescriptions for opioids, length of
opioid treatment, and overdose or suici…
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psnet.ahrq.gov/node/867084/psn-pdf
November 06, 2024 - Effectiveness of artificial intelligence (AI) in clinical
decision support systems and care delivery.
November 6, 2024
Ouanes K, Farhah N. Effectiveness of artificial intelligence (AI) in clinical decision support systems and
care delivery. J Med Syst. 2024;48(1):74. doi:10.1007/s10916-024-02098-4.
https://psnet.a…
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psnet.ahrq.gov/node/44609/psn-pdf
June 21, 2016 - The missing evidence: a systematic review of patients'
experiences of adverse events in health care.
June 21, 2016
Harrison R, Walton M, Manias E, et al. The missing evidence: a systematic review of patients' experiences
of adverse events in health care. Int J Qual Health Care. 2015;27(6):424-42. doi:10.1093/intqhc…
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psnet.ahrq.gov/node/60183/psn-pdf
April 01, 2020 - Elder abuse and neglect: an overlooked patient safety
issue. A focus group study of nursing home leaders'
perceptions of elder abuse and neglect.
April 1, 2020
Myhre J, Saga S, Malmedal W, et al. Elder abuse and neglect: an overlooked patient safety issue. A focus
group study of nursing home leaders’ perceptions o…
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psnet.ahrq.gov/node/60987/psn-pdf
October 07, 2020 - Process failures that increase the risk of infection
through respiratory droplets: a study of patient safety
events reported by hospitals across Pennsylvania.
October 7, 2020
Harper A, Kukielka E, Jones RM. Process failures that increase the risk of infection through respiratory
droplets: a study of patient safety…
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digital.ahrq.gov/location/usa-oh-cincinnati
January 01, 2023 - USA, OH, Cincinnati
Optimal Methods for Notifying Clinicians About Epilepsy Surgery Patients
Description
This research prospectively evaluated a machine learning algorithm that identifies candidates for neurologic surgery to control epilepsy.
Grant Number
R21 HS024977 …
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www.ahrq.gov/cpi/about/otherwebsites/qualityindicators.ahrq.gov/qualityindicators.html
February 01, 2025 - AHRQuality Indicators™
Mission The Quality Indicators are measures of health care quality that use readily available hospital inpatient administrative data. AHRQ develops Quality Indicators to provide health care decisionmakers with tools to assess their data. Visit the AHRQuality Indicators™ Web site . Releva…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/111-cusp-learning-from-defects-worksheet.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Investigating a Defect Worksheet
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion SurgeriesOwner: ____________________________
Date Defect Occurred: ________________
Date Investigation Initiated: ___________
Use the Learning From …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/111-ss-cusp-lfd-worksheet-a3.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Investigating a Defect Worksheet
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion SurgeriesOwner: ____________________________
Date Defect Occurred: ________________
Date Investigation Initiated: ___________
Use the Learning From …
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digital.ahrq.gov/sites/default/files/docs/citation/EHR_Usability_Toolkit_Background_Report.pdf
January 26, 2006 - will guide the development of an
initial Web-based toolkit that supports primary care providers by identifying … We consider that the usability factors outlined
above are sufficient for identifying the majority of … Inclusionary criteria
for this search were similar to those developed for identifying methods initially … There are several advantages to this technique: it is helpful for identifying rare events;
it has high