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psnet.ahrq.gov/issue/what-extent-are-patients-involved-researching-safety-acute-mental-healthcare
August 18, 2021 - Review
To what extent are patients involved in researching safety in acute mental healthcare?
Citation Text:
Brierley-Jones L, Ramsey L, Canvin K, et al. To what extent are patients involved in researching safety in acute mental healthcare? Res Involv Engagem. 2022;8(1):8. doi:10.1186/s4…
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psnet.ahrq.gov/issue/medication-related-emergency-department-visits-pediatrics-prospective-observational-study
October 16, 2013 - Study
Medication-related emergency department visits in pediatrics: a prospective observational study.
Citation Text:
Zed PJ, Black KJL, Fitzpatrick EA, et al. Medication-related emergency department visits in pediatrics: a prospective observational study. Pediatrics. 2015;135(3):435-43.…
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psnet.ahrq.gov/issue/identification-priorities-improvement-medication-safety-primary-care-prioritize-study
October 05, 2016 - Study
Identification of priorities for improvement of medication safety in primary care: a PRIORITIZE study.
Citation Text:
Car LT, Papachristou N, Gallagher J, et al. Identification of priorities for improvement of medication safety in primary care: a PRIORITIZE study. BMC Fam Pract. 20…
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psnet.ahrq.gov/issue/prevalence-and-factors-associated-patient-requested-corrections-medical-record-through-use
October 02, 2024 - Study
Prevalence and factors associated with patient-requested corrections to the medical record through use of a patient portal: findings from a national survey.
Citation Text:
Nguyen OT, Hong Y-R, Alishahi Tabriz A, et al. Prevalence and factors associated with patient-requested correc…
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psnet.ahrq.gov/issue/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
May 12, 2021 - Commentary
The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy.
Citation Text:
Kanter MH, Ghobadi A, Lurvey LD, et al. The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. Diagnosis (Berl). 2022;9(4):430-43…
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psnet.ahrq.gov/issue/implementation-trigger-review-method-scottish-general-practices-patient-safety-outcomes-and
November 07, 2011 - Study
Implementation of the trigger review method in Scottish general practices: patient safety outcomes and potential for quality improvement.
Citation Text:
de Wet C, Black C, Luty S, et al. Implementation of the trigger review method in Scottish general practices: patient safety outco…
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psnet.ahrq.gov/issue/central-venous-catheter-guidewire-retention-lessons-englands-never-event-database
September 15, 2021 - Study
Central venous catheter guidewire retention: lessons from England's never event database.
Citation Text:
Mariyaselvam MZA, Patel V, Young HE, et al. Central venous catheter guidewire retention: lessons from England's never event database. J Patient Saf. 2022;18(2):e387-e392. doi:10…
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psnet.ahrq.gov/issue/screening-medication-errors-using-outlier-detection-system
December 18, 2019 - Study
Screening for medication errors using an outlier detection system.
Citation Text:
Schiff G, Volk LA, Volodarskaya M, et al. Screening for medication errors using an outlier detection system. J Am Med Inform Assoc. 2017;24(2):281-287. doi:10.1093/jamia/ocw171.
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psnet.ahrq.gov/issue/monitoring-harm-associated-use-anticoagulants-pediatric-populations-through-trigger-based
November 11, 2015 - Study
Monitoring the harm associated with use of anticoagulants in pediatric populations through trigger-based automated adverse-event detection.
Citation Text:
Patregnani JT, Spaeder MC, Lemon V, et al. Monitoring the harm associated with use of anticoagulants in pediatric populations t…
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psnet.ahrq.gov/issue/relationships-between-medications-used-mental-health-hospital-and-types-medication-errors
November 29, 2023 - Study
Relationships between medications used in a mental health hospital and types of medication errors: a cross-sectional study over an 8-year period.
Citation Text:
Lebas R, Calvet B, Schadler L, et al. Relationships between medications used in a mental health hospital and types of med…
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psnet.ahrq.gov/issue/interventions-reduce-pediatric-medication-errors-systematic-review
December 04, 2016 - Review
Interventions to reduce pediatric medication errors: a systematic review.
Citation Text:
Rinke ML, Bundy DG, Velasquez CA, et al. Interventions to reduce pediatric medication errors: a systematic review. Pediatrics. 2014;134(2):338-360. doi:10.1542/peds.2013-3531.
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psnet.ahrq.gov/issue/barriers-and-facilitators-reporting-medical-device-related-pressure-ulcers-qualitative
April 07, 2019 - Study
Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration of international practice.
Citation Text:
Crunden EA, Worsley PR, Coleman SB, et al. Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative…
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psnet.ahrq.gov/issue/workarounds-electronic-health-record-systems-and-revised-sociotechnical-electronic-health
October 05, 2022 - Review
Workarounds in electronic health record systems and the revised Sociotechnical Electronic Health Record Workaround Analysis Framework: scoping review.
Citation Text:
Blijleven V, Hoxha F, Jaspers MWM. Workarounds in electronic health record systems and the revised sociotechnical E…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-joy-in-work.pdf
June 02, 2025 - Job Aid: Joy in Work
Primary Care Practice Facilitator
Training Series
1
Job Aid: Joy in Work
Joy in work is one of three categories of common goals practices
have for improvement. Joy in work is central to good patient
care and in recognition of this, the national triple aim has been
expanded to…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/031-hand-hygiene-monitoring.docx
October 01, 2024 - Direct Observation: Covert1-4
Incorporates unknown or undercover (“secret shopper”) observers to facilitate accurate data collection
Advantages
Disadvantages
· Minimizes the Hawthorne effect—the observer’s effect on the behavior being observed
· Identifies trends and barriers to adherence
· Includes possibility t…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/twomorees-slides/Two-More-Es-and-How-to-Spread-Dec-13-2011-508.ppt
January 01, 2011 - Project Report - Lean Sigma
Two More E’s and How to Spread
Learning Objectives
To think ahead about ways to make your investment of time and improvements in BSI rates last forever
To make sure all patients in your institution have access to the same level of safety in their care
Implementation Framework
Al…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/demostates/vtstateataglance.pdf
March 01, 2012 - Vermont State at a Glance
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psnet.ahrq.gov/issue/assessing-system-thinking-senior-pharmacy-students-using-innovative-horror-room-simulation
May 01, 2004 - Study
Assessing system thinking in senior pharmacy students using the innovative "Horror Room" simulation setting: a cross-sectional survey of a non-technical skill.
Citation Text:
Aljuffali LA, Almalag HM, Alnaim L. Assessing system thinking in senior pharmacy students using the innovat…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/webinar-012220-shaller.pdf
June 02, 2025 - Understanding CAHPS® Surveys: A Primer for New Users - Shaller
HOW ARE SURVEY RESULTS
USED?
Dale Shaller, M.P.A.
Principal
Shaller Consulting Group
How Are Survey Results Used?
• Quality improvement
• Public reporting
• Value-based payment
• Recognition and certification
• Research
30
Using CAHPS Surve…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/quiz-key.html
March 01, 2017 - Catheter Care and Maintenance Quiz Key
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
1. During catheter care, gloves only need to be worn if you are emptying the urine drainage bag.
☐ True ☒ False
ANSWER: False. Gloves should always be worn when handling an indwelling urinary ca…