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digital.ahrq.gov/ahrq-funded-projects/patient-reminders-and-notifications
January 01, 2023 - Patient Reminders and Notifications
Project Final Report ( PDF , 557.74 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in t…
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psnet.ahrq.gov/issue/implementation-hand-hygiene-health-care-facilities-results-who-hand-hygiene-self-assessment
September 09, 2020 - Study
Implementation of hand hygiene in health-care facilities: results from the WHO Hand Hygiene Self-Assessment Framework global survey 2019.
Citation Text:
de Kraker MEA, Tartari E, Tomczyk S, et al. Implementation of hand hygiene in health-care facilities: results from the WHO Hand H…
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digital.ahrq.gov/ahrq-funded-projects/medication-monitoring-vulnerable-populations-information-technology-mmiti/annual-summary/2010
January 01, 2010 - Medication Monitoring for Vulnerable Populations via Information Technology (MMITI) - 2010
Project Name
Medication Monitoring for Vulnerable Populations via Information Technology (MMITI)
Principal Investigator
Lehmann, Christoph
Organization
Johns Hopkins University
…
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psnet.ahrq.gov/node/35010/psn-pdf
May 18, 2005 - Hospital-error oversight called lax: state takes too long to
investigate mistakes, patient advocates say.
May 18, 2005
Galloway A. Seattle Post-Intelligencer. May 4, 2005.
https://psnet.ahrq.gov/issue/hospital-error-oversight-called-lax-state-takes-too-long-investigate-mistakes-
patient
This article explores…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7c.pdf
June 02, 2025 - Section 7C
Table VII.C.1 – Distribution of insurance types and adverse events across sites based on
GAPPS study analytic sample (n = 3,151)
Insurance n (%) AE rate P-Value
Medicaid 1,216 (38.6%) 0.14 Refe…
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psnet.ahrq.gov/node/35009/psn-pdf
May 27, 2011 - Guided prescription of psychotropic medications for
geriatric inpatients.
May 27, 2011
Peterson JF, Kuperman GJ, Shek C, et al. Guided prescription of psychotropic medications for geriatric
inpatients. Arch Intern Med. 2005;165(7):802-7.
https://psnet.ahrq.gov/issue/guided-prescription-psychotropic-medications-ger…
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digital.ahrq.gov/ahrq-funded-projects/preventing-wrong-drug-and-wrong-patient-errors-indication-alerts-cpoe-systems/citation/beyond
January 01, 2023 - Beyond mixed case lettering: Reducing the risk of wrong drug errors requires a multimodal response.
Citation
Lambert BL, Schroeder SR, Cohen MR, Paparella S. Beyond mixed case lettering: Reducing the risk of wrong drug errors requires a multimodal response. BMJ Qual Saf. 2023 Jan;32(1):6-9. doi: 10.11…
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digital.ahrq.gov/ahrq-funded-projects/quality-indicators-care-coordination-measures-project/publication/care
January 01, 2023 - Care coordination measures atlas
Citation
McDonald KM, Schultz E, Albin L, et al. Care coordination measures atlas (Prepared by Stanford University under subcontract to Battelle on Contract No. 290-04-0020). AHRQ Publication No. 11-0023-EF. Rockville, MD: Agency for Healthcare Research and Quality. No…
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psnet.ahrq.gov/node/42184/psn-pdf
December 18, 2013 - Why don't we know whether care is safe?
December 18, 2013
Pham JC, Frick KD, Pronovost P. Why don't we know whether care is safe? Am J Med Qual.
2013;28(6):457-63. doi:10.1177/1062860613479397.
https://psnet.ahrq.gov/issue/why-dont-we-know-whether-care-safe
This commentary discusses barriers to understanding and m…
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cds.ahrq.gov/sites/default/files/cds/artifact/logic/2023-10/CQL%20to%20CDS%20Hooks%20cards_0.txt
January 01, 2023 - Mapping of CQL conditions to CDS Hooks cards
Condition: NoDDimerNoWells
Card: It is recommended to assess the patient's risk for pulmonary embolism (PE) and evaluate D-dimer levels before proceeding with a CTPA order. Use the following link to evaluate the risk.
Launch Questionnaire: Yes
Condition: NoDDimerWellsLessT…
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psnet.ahrq.gov/node/35357/psn-pdf
February 03, 2011 - Effects of work hour reduction on residents' lives: a
systematic review.
February 3, 2011
Fletcher KE, Underwood W, Davis SQ, et al. Effects of Work Hour Reduction on Residents’ Lives. JAMA.
2005;294(9):1088. doi:10.1001/jama.294.9.1088.
https://psnet.ahrq.gov/issue/effects-work-hour-reduction-residents-lives-syst…
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psnet.ahrq.gov/node/34815/psn-pdf
January 31, 2011 - The role of anesthesia in surgical mortality.
January 31, 2011
DRIPPS RD, LAMONT A, ECKENHOFF JE. The role of anesthesia in surgical mortality. JAMA.
1961;178:261-6.
https://psnet.ahrq.gov/issue/role-anesthesia-surgical-mortality
The authors of this study characterized the attributable mortality rate from anesthes…
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psnet.ahrq.gov/node/39642/psn-pdf
December 21, 2014 - Effect of the 50-hour workweek limitation on training of
surgical residents in Switzerland.
December 21, 2014
Businger A, Guller U, Oertli D. Effect of the 50-hour workweek limitation on training of surgical residents in
Switzerland. Arch Surg. 2010;145(6):558-63. doi:10.1001/archsurg.2010.88.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/38161/psn-pdf
October 22, 2008 - Discrepancies between home medications listed at
hospital admission and reported medical conditions.
October 22, 2008
Slain D, Kincaid SE, Dunsworth TS. Discrepancies between home medications listed at hospital admission
and reported medical conditions. Am J Geriatr Pharmacother. 2008;6(3):161-6.
doi:10.1016/j.amj…
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psnet.ahrq.gov/node/50717/psn-pdf
December 04, 2019 - Canada continues to lag behind other OECD countries on
measures of patient safety
December 4, 2019
Canadian Institute for Health Information. Ottawa, ON: Canadian Institute for Health Information; 2019.
https://psnet.ahrq.gov/issue/canada-continues-lag-behind-other-oecd-countries-measures-patient-safety
This fact …
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psnet.ahrq.gov/node/35090/psn-pdf
June 22, 2009 - Improving end of life care: an information systems
approach to reducing medical errors.
June 22, 2009
Tamang S, Kopec D, Shagas G, et al. Improving end of life care: an information systems approach to
reducing medical errors. Stud Health Technol Inform. 2005;114:93-104.
https://psnet.ahrq.gov/issue/improving-end-l…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-166-fecc-table-6.pdf
June 02, 2025 - Section 6, Table 6 Construct Measurement Reliability Testing
Table 6: Construct measurement reliability testing for multi-part indicators
Number
of items
Average
inter-item
polychoric
correlation
Polychoric
Ordinal
Alp…
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psnet.ahrq.gov/node/47649/psn-pdf
January 09, 2019 - ASH Clinical Practice Guidelines on Venous
Thromboembolism.
January 9, 2019
Washington DC; American Society of Hematology.
https://psnet.ahrq.gov/issue/ash-clinical-practice-guidelines-venous-thromboembolism
The American Society of Hematology produced a series of guidelines on prophylaxis for venous
thromboemboli…
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psnet.ahrq.gov/node/60042/psn-pdf
March 11, 2020 - At Walgreens, complaints of medication errors go
missing.
March 11, 2020
Gabler E. New York Times. February 23, 2020.
https://psnet.ahrq.gov/issue/walgreens-complaints-medication-errors-go-missing
Response to reported safety concerns is a primary indicator of an organizational commitment to reducing
and lear…
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psnet.ahrq.gov/node/40516/psn-pdf
July 15, 2013 - Characteristics of unsafe undergraduate nursing students
in clinical practice: an integrative literature review.
July 15, 2013
Killam LA, Luhanga F, Bakker D. Characteristics of unsafe undergraduate nursing students in clinical
practice: an integrative literature review. J Nurs Educ. 2011;50(8):437-46. doi:10.3928/…