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psnet.ahrq.gov/issue/learning-mistakes-easier-said-done-group-and-organizational-influences-detection-and
September 25, 2024 - Study
Classic
Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error.
Citation Text:
Edmondson AC. Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences o…
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psnet.ahrq.gov/issue/education-initiatives-cognitive-debiasing-improve-diagnostic-accuracy-student-providers
October 21, 2020 - Review
Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: a scoping review.
Citation Text:
Griffith PB, Doherty C, Smeltzer SC, et al. Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: a scopin…
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psnet.ahrq.gov/issue/adherence-drug-drug-interaction-alerts-high-risk-patients-trial-context-enhanced-alerting
February 21, 2018 - Study
Adherence to drug–drug interaction alerts in high-risk patients: a trial of context-enhanced alerting.
Citation Text:
Duke JD, Li X, Dexter P. Adherence to drug-drug interaction alerts in high-risk patients: a trial of context-enhanced alerting. J Am Med Inform Assoc. 2013;20(3):49…
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psnet.ahrq.gov/issue/impact-pharmacist-interventions-medication-errors-hospitalized-pediatric-patients-systematic
August 04, 2021 - Review
Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis.
Citation Text:
Naseralallah LM, Hussain TA, Jaam M, et al. Impact of pharmacist interventions on medication errors in hospitalized pediatric patients:…
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www.ahrq.gov/news/newsroom/case-studies/ktcoe33.html
October 01, 2014 - Iowa Medicaid Uses AHRQ Research, Data to Improve Quality
Search All Impact Case Studies
March 2010
As a result of participating in the Medicaid Medical Directors Learning Network—an AHRQ Knowledge Transfer project—the Iowa Medicaid Enterprise, in consultation with the Iowa Foundation for Medical Care, used…
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cdsic.ahrq.gov/sites/default/files/2023-08/CDSiC%20App%20Interoperability%20Report_508.pdf
January 01, 2023 - critical reading (e.g., blood pressure reading
indicative of hypertensive crisis, or PHQ-9 response indicating
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www.ahrq.gov/sites/default/files/2025-05/silber-report.pdf
January 01, 2025 - complications included
any patient who had a diagnosis that was not POA or who received a
procedure indicating
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/burnout-in-primary-care.pdf
February 01, 2023 - documentation, order entry, billing and coding, and security issues (i.e.,
usernames and passwords),40 indicating
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cancer-radiation_executive.pdf
November 01, 2009 - Layout 1
Background
Radiotherapy with charged particles can
potentially deliver maximal doses while
minimizing irradiation of surrounding
tissues. It may be more effective or less
harmful than other forms of radiotherapy
for some cancers. Currently, seven centers
in the United States have facilities for
particle (pr…
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effectivehealthcare.ahrq.gov/sites/default/files/developmental-delays-horizon-scan-high-impact-1506.pdf
December 01, 2015 - #06 Developmental Delays ADHD, and Autism
AHRQ Healthcare Horizon Scanning System – Potential
High-Impact Interventions Report
Priority Area 06: Developmental Delays, ADHD,
and Autism
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaithe…
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hcup-us.ahrq.gov/db/nation/nis/tools/stats/FileSpecifications_NIS_2006_Core.TXT
January 01, 2006 - Data Set Name: NIS_2006_CORE
Number of Observations: 8074825
Total Record Length: 510
Total Number of Data Elements: 128
Columns Description
======= ===========
1- 3 Database name
5- 8 Discharge year of data
10- 25 File name
27- 29 Data element number
31- 59 Data element name…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar4_pu_skinassesst_final.pdf
April 01, 2011 - Conducting a Comprehensive Skin Assessment
Conducting a Comprehensive
Skin Assessment
Presented by
Dr. Karen Zulkowski, D.N.S., RN
Montana State University
Welcome!
Thank you for joining this webinar about how to
conduct a comprehensive skin assessment.
2
A Little About Myself…
• An associate professo…
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psnet.ahrq.gov/node/49413/psn-pdf
September 01, 2003 - Did We Forget Something?
September 1, 2003
Gibbs VC. Did We Forget Something? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/did-we-forget-something
The Case
A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially
attributed to ventilator-associated pneumo…
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psnet.ahrq.gov/node/33821/psn-pdf
December 01, 2016 - Errors and Near Misses: What Health Care Could Learn
From Aviation
December 1, 2016
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
Perspective
Some of the most urg…
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - Secured But Not Always Safe
Citation Text:
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML …
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psnet.ahrq.gov/web-mm/misread-label
August 28, 2024 - Misread Label
Citation Text:
Franklin BD. Misread Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49791/psn-pdf
April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the
Preventable
April 1, 2017
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
The Case
An 84-year-old wo…
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psnet.ahrq.gov/node/33808/psn-pdf
May 01, 2016 - Reducing the Safety Hazards of Monitor Alert and Alarm
Fatigue
May 1, 2016
Jacques S, Williams E. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue. PSNet [internet].
2016.
https://psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
Perspective
Alarm fatigue occurs whe…
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meps.ahrq.gov/data_files/publications/st146/stat146.pdf
October 01, 2006 - Statistical Brief #146: Proportion and Medical Expenditures of Adults Being Treated for Diabetes, 1996 and 2003
Medical Expenditure Panel Survey
Agen
Res
6
October 2006
Proportion and Medical Expenditures of
Adults Being Treated for Diabetes, 1996
and 2003 Betw
the p
at le
for t…
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psnet.ahrq.gov/node/49449/psn-pdf
June 01, 2004 - Lethal Vertigo
June 1, 2004
Furman JM. Lethal Vertigo. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-vertigo
The Case
A 64-year-old woman, with no prior medical history, complained of sudden onset of severe vertigo and
vomiting, without headache. Her initial blood pressure in the emergency departme…