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  1. psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance
    November 18, 2020 - Commentary Organizational learning: health care leaders need to design structures and processes that enhance collective learning. Citation Text: Bohmer RM, Edmondson AC. Organizational learning in health care. Health Forum J. 2001;44(2):32-35. Copy Citation Format: Google…
  2. integrationacademy.ahrq.gov/sites/default/files/2021-09/PHQ-9.pdf
    January 01, 2021 - Patient Health Questionnaire (PHQ-9) PATIENT HEALTH QUESTIONNAIRE (PHQ-9) NAME: DATE: Over the last 2 weeks, how often have you been bothered by any of the following problems? (use "ⁿ" to indicate your answer) Not at all Several days More than half the days Nearly every day 1. Little interest…
  3. psnet.ahrq.gov/issue/making-business-case-patient-safety
    March 04, 2011 - Commentary Making the business case for patient safety. Citation Text: Weeks WB, Bagian JP. Making the business case for patient safety. Jt Comm J Qual Saf. 2003;29(1):51-4, 1. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
  4. digital.ahrq.gov/program-overview/research-stories/clinical-decision-support-tool-preventing-falls
    January 01, 2023 - A Clinical Decision Support Tool for Preventing Falls Theme: Optimizing Care Delivery for Clinicians Subtheme: Scaling Effective and Interoperable CDS to Improve Care and Decision Making Tools like ASPIRE that integrate fall prevention clinical decision support and patient resources may be…
  5. psnet.ahrq.gov/issue/predictors-nursing-home-nurses-willingness-report-medication-near-misses
    July 31, 2024 - Study Predictors of nursing home nurses' willingness to report medication near-misses. Citation Text: Farag A, Vogelsmeier A, Knox K, et al. Predictors of nursing home nurses' willingness to report medication near-misses. J Gerontol Nurs. 2020;46(4):21-30. doi:10.3928/00989134-20200303-0…
  6. integrationacademy.ahrq.gov/news-and-events/news/opioid-epidemic-and-covid-19-pandemic-dual-crises
    December 23, 2020 - An official website of the Department of Health & Human Services Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates The Academy Integrating Behavioral Health & Primary Care Expand Navi…
  7. psnet.ahrq.gov/issue/evaluation-electronic-health-record-implementation-pharmacist-interventions-related-oral
    January 25, 2023 - Study Evaluation of electronic health record implementation on pharmacist interventions related to oral chemotherapy management. Citation Text: Finn A, Bondarenka C, Edwards K, et al. Evaluation of electronic health record implementation on pharmacist interventions related to oral chemot…
  8. psnet.ahrq.gov/issue/obstetrician-gynecologist-views-pregnancy-related-medication-safety
    July 29, 2020 - Study Obstetrician-gynecologist views of pregnancy-related medication safety. Citation Text: SteelFisher GK, Hero JO, Caporello HL, et al. Obstetrician-gynecologist views of pregnancy-related medication safety. J Womens Health (Larchmt). 2020;29(8):1113-1121. doi:10.1089/jwh.2019.8007. …
  9. psnet.ahrq.gov/issue/linking-acknowledgement-action-closing-loop-non-urgent-clinically-significant-test-results
    July 02, 2019 - Study Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record. Citation Text: Dalal A, Pesterev BM, Eibensteiner K, et al. Linking acknowledgement to action: closing the loop on non-urgent, clinically signific…
  10. psnet.ahrq.gov/issue/improving-quality-insulin-prescribing-people-diabetes-being-discharged-hospital
    November 16, 2022 - Journal Article Improving the quality of insulin prescribing for people with diabetes being discharged from hospital Citation Text: Bain A, Silcock J, Kavanagh S, et al. Improving the quality of insulin prescribing for people with diabetes being discharged from hospital. BMJ Open Qual. 2…
  11. psnet.ahrq.gov/issue/pending-studies-hospital-discharge-pre-post-analysis-electronic-medical-record-tool-improve
    September 16, 2020 - Study Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge. Citation Text: Kantor MA, Evans KH, Shieh L. Pending studies at hospital discharge: a pre-post analysis of an electronic medical record to…
  12. psnet.ahrq.gov/issue/assessment-impact-just-culture-quality-and-safety-us-hospitals
    April 13, 2017 - Study Emerging Classic An assessment of the impact of just culture on quality and safety in US hospitals. Citation Text: Edwards MT. An Assessment of the Impact of Just Culture on Quality and Safety in US Hospitals. Am J Med Qual. 2018;33(5):502-508. doi:10.1177…
  13. 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…
  14. psnet.ahrq.gov/issue/comprehensive-departmental-care-review-model-requirements-structure-and-flow
    July 06, 2022 - Commentary A comprehensive departmental care review model: requirements, structure, and flow. Citation Text: Nestler DM, Laack TA, Scanlan-Hanson L, et al. A comprehensive departmental care review model: requirements, structure, and flow. Jt Comm J Qual Patient Saf. 2021;47(8):503-509. d…
  15. psnet.ahrq.gov/issue/injury-and-liability-associated-monitored-anesthesia-care-closed-claims-analysis
    June 23, 2009 - Study Injury and liability associated with monitored anesthesia care: a closed claims analysis. Citation Text: Bhananker SM, Posner KL, Cheney FW, et al. Injury and liability associated with monitored anesthesia care: a closed claims analysis. Anesthesiology. 2006;104(2):228-234. Cop…
  16. psnet.ahrq.gov/issue/factors-associated-malpractice-claim-payout-analysis-closed-emergency-department-claims
    May 18, 2022 - Study Factors associated with malpractice claim payout: an analysis of closed emergency department claims. Citation Text: Gupta K, Szymonifka J, Rivadeneira NA, et al. Factors associated with malpractice claim payout: an analysis of closed emergency department claims. Jt Comm J Qual Pati…
  17. psnet.ahrq.gov/issue/what-causes-medication-administration-errors-mental-health-hospital-qualitative-study-nursing
    March 11, 2020 - Study What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. Citation Text: Keers RN, Plácido M, Bennett K, et al. What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff. …
  18. psnet.ahrq.gov/issue/adverse-events-anesthesia-integrative-review
    October 16, 2024 - Review Adverse Events in Anesthesia: An Integrative Review. Citation Text: Lemos C de S, Poveda V de B. Adverse Events in Anesthesia: An Integrative Review. J Perianesth Nurs. 2019;34(5):978-998. doi:10.1016/j.jopan.2019.02.005. Copy Citation Format: DOI Google Scholar Pub…
  19. psnet.ahrq.gov/issue/root-cause-analysis-adverse-events-involving-opioid-overdoses-veterans-health-administration
    November 17, 2021 - Study Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration. Citation Text: Norris B, Soncrant C, Mills PD, et al. Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration. Jt Comm J Qual Patie…
  20. 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:…