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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845657/psn-pdf
    March 08, 2023 - Dissemination and Implementation of Equity-Focused Evidence-Based Interventions in Healthcare Delivery Systems (R18). March 8, 2023 Rockville, MD: Agency for Healthcare Research and Quality. February 15, 2023. RFA-HS-23-002. https://psnet.ahrq.gov/issue/dissemination-and-implementation-equity-focused-evidence-base…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867748/psn-pdf
    March 12, 2025 - Adverse events involving telehealth in the Veterans Health Administration. March 12, 2025 Mills PD, Tomolo A, Yackel EE. Adverse events involving telehealth in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2024;Epub Dec 20. doi:10.1016/j.jcjq.2024.12.002. https://psnet.ahrq.gov/issue/adverse-even…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836792/psn-pdf
    March 23, 2022 - Remote patient monitoring during COVID-19: an unexpected patient safety benefit. March 23, 2022 Pronovost PJ, Cole MD, Hughes RM. Remote patient monitoring during COVID-19: an unexpected patient safety benefit. JAMA. 2022;327(12):1125-1126. doi:10.1001/jama.2022.2040. https://psnet.ahrq.gov/issue/remote-patient-mo…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836757/psn-pdf
    March 16, 2022 - Improving communication and teamwork during labor: a feasibility, acceptability, and safety study. March 16, 2022 Weiseth A, Plough A, Aggarwal R, et al. Improving communication and teamwork during labor: A feasibility, acceptability, and safety study. Birth. 2022;49(4):637-647. doi:10.1111/birt.12630. https://psn…

  5. CHIIPRA 194: Section 6, Table 12 (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-194-section-6-table-12.pdf
    June 02, 2025 - CHIIPRA 194: Section 6, Table 12 Table 12: ICD-9-CM Codes to Identify Signs and Symptoms of Increased Intracranial Pressure or Herniation Diagnosis Category Diagnosis Detail ICD-9-CM Code Visual disturbances Diplopia 368.2 Other disorders of eyelids Ptosis 374.3 Disorders of the optic nerve and visual …

  6. Event Investigation and Analysis Guide: Appendix H | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/aph.html
    August 01, 2022 - Event Investigation and Analysis Guide: Appendix H Hierarchy of Solutions Do solutions meet the following criteria: Address the root cause/contributing factor. Are specific and concrete. Can be understood and implemented by a reader unfamiliar with the situation. Will be tested or simulated prior to…

  7. Exhibit 5.5. Organizational Goals of Lean | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit5-5.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 5.5. Organizational Goals of Lean Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare Case 2. Central H…

  8. AHRQ Strategic Plan for Health System Transformation To Optimize Health, Functional Status, and Well-Being Among Older Adults | Agency for Healthcare Research and Quality

    www.ahrq.gov/priority-populations/publications/aging-well.html
    July 01, 2024 - AHRQ Strategic Plan for Health System Transformation To Optimize Health, Functional Status, and Well-Being Among Older Adults The U.S. population is rapidly aging, and the health system is ill-prepared to meet the needs of older adults. Older adults and individuals with multiple chronic conditions frequently re…

  9. Conclusion | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults4.html
    September 01, 2024 - State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults Conclusion Previous Page Next 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 …

  10. View PDF (pdf file)

    integrationacademy.ahrq.gov/print/pdf/node/23253
    View PDF Center for Psychology & Health View PDF Website https://www.apa.org/health Mission To promote the advancement, communication, and application of psychological science and knowledge to benefit society and improve lives.  Location Washington, DC United States Terms of Use May require fee or membership De…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867757/psn-pdf
    March 12, 2025 - Improving medication-related safety for residents in nursing homes: a qualitative study. March 12, 2025 Shieu B, Lee Y-W, Epps F, et al. Improving medication-related safety for residents in nursing homes: a qualitative study. J Gerontol Nurs. 2025;51(3):38-43. doi:10.3928/00989134-20250102-03. https://psnet.ahrq.g…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842424/psn-pdf
    January 11, 2023 - Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals. January 11, 2023 Pratt BR, Dunford BB, Vogus TJ, et al. Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals. Health Care Manage Rev. 2022;48(1):14-22. doi:10.1097/hmr.0000000000000351. https://p…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44050/psn-pdf
    September 27, 2017 - Unfinished nursing care, missed care, and implicitly rationed care: state of the science review. September 27, 2017 Jones TL, Hamilton P, Murry N. Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. Int J Nurs Stud. 2015;52(6):1121-1137. doi:10.1016/j.ijnurstu.2015.02.01…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36734/psn-pdf
    March 10, 2011 - Integrating incident reporting into an electronic patient record system. March 10, 2011 Haller G, Myles PS, Stoelwinder J, et al. Integrating incident reporting into an electronic patient record system. J Am Med Inform Assoc. 2007;14(2):175-81. https://psnet.ahrq.gov/issue/integrating-incident-reporting-electronic…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48022/psn-pdf
    May 29, 2019 - Inappropriate opioid prescription after surgery. May 29, 2019 Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. Lancet. 2019;393(10180):1547-1557. doi:10.1016/S0140-6736(19)30428-3. https://psnet.ahrq.gov/issue/inappropriate-opioid-prescription-after-surgery The overprescribing of o…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837777/psn-pdf
    August 03, 2020 - To err is human, unless you are a healthcare provider. August 3, 2020 Zajicek J. Belmont Health Law J. 2020;4:79-135. https://psnet.ahrq.gov/issue/err-human-unless-you-are-healthcare-provider Intent to harm is a primary factor in the criminalization of patient injury. This article discusses the increase of crimina…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47192/psn-pdf
    January 23, 2019 - Barriers to self-reporting patient safety incidents by paramedics: a mixed methods study. January 23, 2019 Sinclair JE, Austin MA, Bourque C, et al. Barriers to Self-Reporting Patient Safety Incidents by Paramedics: A Mixed Methods Study. Prehosp Emerg Care. 2018;22(6):762-772. doi:10.1080/10903127.2018.1469703. h…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44231/psn-pdf
    January 22, 2016 - Just-in-time training for high-risk low-volume therapies: an approach to ensure patient safety. January 22, 2016 Helman S, Lisanti AJ, Adams A, et al. Just-in-Time Training for High-Risk Low-Volume Therapies: An Approach to Ensure Patient Safety. J Nurs Care Qual. 2016;31(1):33-9. doi:10.1097/NCQ.0000000000000131.…

  19. USA, VT, Windsor | Digital Healthcare Research

    digital.ahrq.gov/location/usa-vt-windsor
    January 01, 2023 - USA, VT, Windsor Clinical Portal Survey: Mt. Ascutney Hospital and Health Center Description This is a questionnaire designed to be completed by nurses, physicians, and hospital staff in an inpatient setting. The tool includes questions to assess user's needs of electronic hea…

  20. AHRQ PSNet Webinar (pdf file)

    psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
    January 01, 2025 - AHRQ PSNet Webinar AHRQ PSNet Webinar Making Healthcare Safer (MHS) IV: Rapid Response Systems and Opioid Stewardship February 10, 2025 Agenda 2 • Logistics • Introduction to the Making Healthcare Safer (MHS) IV Reports • Report 1 – Rapid Response Systems ► Discussion ► PSNet Resources • Report 2 – Opioi…
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