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  1. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Bernard.pdf
    January 01, 2004 - Financial and Demographic Influences on Medicare Patient Safety Events 437 Financial and Demographic Influences on Medicare Patient Safety Events Didem Bernard, William E. Encinosa Abstract Background: The hospital market is stratified between the “have” and the “have not” hospitals. Whether financial dis…
  2. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
    April 22, 2004 - Work System Analysis: The Key to Understanding Health Care Systems 337 Work System Analysis: The Key to Understanding Health Care Systems Ben-Tzion Karsh, Samuel J. Alper Abstract Many articles in the medical literature state that medical errors are the result of systems problems, require systems analyses, a…
  3. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
    April 20, 2004 - Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation 437 Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation Mary V. Wideman, Michael E. Whittler, Timothy M. Anderson Abstract An electronic barcode medication administration sy…
  4. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Alexander_10.pdf
    January 20, 2008 - Measuring IT Sophistication in Nursing Homes Measuring IT Sophistication in Nursing Homes Gregory L. Alexander, PhD, RN; Dick Madsen, PhD; Stephanie Herrick; Brady Russell Abstract Objective: Little activity has occurred in nursing home (information technology) IT adoption. The purpose of this study was to de…
  5. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
    March 26, 2008 - Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse…
  6. psnet.ahrq.gov/perspective/conversation-charles-crecelius-md-phd-cmd-and-lori-l-popejoy-phd-rn-faan
    October 28, 2020 - In Conversation With... Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN October 28, 2020  Also Read the Essay Citation Text: In Conversation With.. Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN. PSNet [internet]. 2020.In C…
  7. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/049-dec-implementation-slides.pptx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention AHRQ Safety Program for MRSA Prevention Implementation of Chlorhexidine Gluconate (CHG) Bathing and Nasal Decolonization ICU & Non-ICU AHRQ Pub. No. 25-0007 October 2024 AHRQ Safety Program for MRSA Prevention | ICU & Non-ICU AHRQ Safety Program for MRSA Prevention | ICU & No…
  8. www.ahrq.gov/sites/default/files/2025-03/hinson-levin-report.pdf
    January 01, 2025 - Final Progress Report: Connected Emergency Care (CEC) Patient Safety Learning Lab • Title of Project: Connected Emergency Care (CEC) Patient Safety Learning Lab • Principal Investigators: Jeremiah S. Hinson, MD, PhD, and Scott R. Levin, PhD • Team Members: Jeremiah Hinson, MD, PhD, Scott Levin, PhD, Eili Klein, Ph…
  9. www.ahrq.gov/sites/default/files/wysiwyg/priority-populations/aging-well-strategic-plan.pdf
    August 01, 2024 - AHRQ Strategic Plan for Health System Transformation To Optimize Health, Functional Status, and Well-Being Among Older Adults 1 Vision: All people receive high-quality, person-centered care based in primary care that optimizes health, functional status, and well-being as they age, and advances health equity. The P…
  10. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults-references.html
    September 01, 2024 - State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults References Previous Page   Table of Contents State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults Introduction Unique Challenges in Approaching Diagnostic Safety in Older Ad…
  11. www.ahrq.gov/sites/default/files/2025-03/rinke2-report.pdf
    January 01, 2025 - Final Progress Report: Comprehensive Pediatric Hypertension Diagnosis and Management 1. TITLE PAGE Comprehensive Pediatric Hypertension Diagnosis and Management Principal Investigator: Michael L. Rinke, MD, PhD Co-Investigators: David G. Bundy, MD, MPH, Tammy M. Brady, MD, PhD, Beth Tarini, MD, Katherine E. Twomb…
  12. www.ahrq.gov/sites/default/files/2024-01/joseph1-report.pdf
    January 01, 2024 - AHRQ Final report: Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process TITLE PAGE Project Title: Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process Principal Investigator: Anjali Joseph, PhD, EDAC Tea…
  13. www.ahrq.gov/sites/default/files/2024-02/zierler-report.pdf
    January 01, 2024 - Final Progress Report: VTE Safety Toolkit: A Systems Approach to Patient Safety Title: VTE Safety Toolkit: A Systems Approach to Patient Safety Principal Investigator: Brenda K. Zierler, PhD1 Team Members: Ann Wittkowsky, PharmD2 Robb Glenny, MD3 Seth Wolpin, PhD1 Jung-Ah Lee, MN1 Gene Peterson, MD, PhD3 Fre…
  14. www.ahrq.gov/sites/default/files/2024-03/bruzzese2-report.pdf
    January 01, 2024 - Final Progress Report: Health Journalism 2010, national conference on healthcare journalism Final Grant Report for Agency for Healthcare Research and Quality Title: Principal Investigator: Organization: Grant Period: Federal Project Officer: Acknowledgement of Agency Support: Grant Number: Health Journalis…
  15. www.ahrq.gov/sites/default/files/2024-07/middleton-wald-report.pdf
    January 01, 2024 - Final Progress Report: Shared Online Health Records for Patient Safety and Care FINAL REPORT: December, 18th 2007 Shared Online Health Records for Patient Safety and Care Principal Investigator: Blackford Middleton, MD, MPH, MSc; bmiddleton1@partners.org Brigham and Women’s Hospital Blackford Middleton, MD, MPH,…
  16. psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
    May 01, 2013 - Strengthening the Business Case for Patient Safety Peter K. Lindenauer, MD, MSc | May 1, 2013  Also Read a Conversation View more articles from the same authors. Citation Text: Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. …
  17. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
    January 01, 2021 - Spotlight Spotlight Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations Source and Credits • This presentation is based on the September 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary …
  18. psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
    August 01, 2018 - How Does Health Care Simulation Affect Patient Care? Joseph O. Lopreiato, MD, MPH | August 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Lopreiato JO. How Does Health Care Simulation Affect Patient Care?. PSNet [inter…
  19. effectivehealthcare.ahrq.gov/sites/default/files/pdf/health-information-exchange_research-protocol.pdf
    April 20, 2015 - Amendment_HIE-Protocol_3-14-2015 Source: www.effectivehealthcare.ahrq.gov Published online: April 20, 2015 Evidence-based Practice Center Systematic Review Protocol Project Title: Health Information Exchange Amendment Date applicable: March 12, 2015 (Amendments Details–see Section VII) I. Background an…
  20. digital.ahrq.gov/sites/default/files/docs/publication/r01hs015321-guise-final-report-2009.pdf
    January 01, 2009 - Improving Safety and Quality with Integrated Technology Grant Final Report Grant ID: 5R01HS015321 Improving Safety and Quality with Integrated Technology Inclusive Dates: 09/30/04 - 08/31/09 Principal Investigator: Jeanne-Marie Guise, MD, MPH Team Members: Dale Kraemer, PhD, OHS…