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  1. www.ahrq.gov/news/blog/ahrqviews/eliminate-diagnostic-errors.html
    August 01, 2022 - AHRQ Views: Blog posts from AHRQ leaders AHRQ Expands Its Repertoire to Eliminate Diagnostic Errors AUG 22 2022 By Robert Otto Valdez, Ph.D., M.H.S.A. R. Valdez, Ph.D., M.H.S.A. Too many Americans have experienced the health-related consequences and anxieties that f…
  2. psnet.ahrq.gov/issue/preventing-hospital-acquired-infections-national-survey-practices-reported-us-hospitals-2005
    July 03, 2014 - Study Preventing hospital-acquired infections: a national survey of practices reported by U.S. hospitals in 2005 and 2009. Citation Text: Krein SL, Kowalski CP, Hofer TP, et al. Preventing hospital-acquired infections: a national survey of practices reported by U.S. hospitals in 2005 and…
  3. psnet.ahrq.gov/issue/prevention-ventilator-associated-pneumonia-evidence-based-systematic-review
    July 14, 2010 - Study Classic Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Citation Text: Collard HR, Saint S, Matthay MA. Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Ann Intern Med. 2003;138(6):49…
  4. psnet.ahrq.gov/issue/multi-site-assessment-inpatient-safety-event-rates-during-coronavirus-disease-2019-pandemic
    May 25, 2022 - Commentary A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic. Citation Text: Pollock BD, Dykhoff HJ, Breeher LE, et al. A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic. Mayo Clin Proc …
  5. psnet.ahrq.gov/issue/two-fatal-cases-accidental-intrathecal-vincristine-administration-learning-death-events
    March 24, 2021 - Commentary Two fatal cases of accidental intrathecal vincristine administration: learning from death events. Citation Text: Chotsampancharoen T, Sripornsawan P, Wongchanchailert M. Two fatal cases of accidental intrathecal vincristine administration: learning from death event. Chemothera…
  6. psnet.ahrq.gov/issue/efficacy-medical-team-training-improved-team-performance-and-decreased-operating-room-delays
    October 06, 2016 - Study The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases. Citation Text: Wolf FA, Way LW, Stewart L. The efficacy of medical team training: improved team performance and decreased operating room delays…
  7. psnet.ahrq.gov/issue/improving-approach-defining-classifying-reporting-and-monitoring-adverse-events-seriously-ill
    July 29, 2020 - Commentary Improving the approach to defining, classifying, reporting and monitoring adverse events in seriously ill older adults: recommendations from a multi-stakeholder convening. Citation Text: Baim-Lance A, Ferreira KB, Cohen HJ, et al. Improving the approach to defining, classifyin…
  8. psnet.ahrq.gov/issue/impact-traditional-and-smart-pump-infusion-technology-nurse-medication-administration
    May 18, 2022 - Study The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit. Citation Text: Trbovich PL, Pinkney S, Cafazzo JA, et al. The impact of traditional and smart pump infusion technology on nurse medication ad…
  9. psnet.ahrq.gov/issue/analysis-adverse-events-associated-adult-moderate-procedural-sedation-outside-operating-room
    August 13, 2014 - Study Analysis of adverse events associated with adult moderate procedural sedation outside the operating room. Citation Text: Karamnov S, Sarkisian N, Grammer R, et al. Analysis of Adverse Events Associated With Adult Moderate Procedural Sedation Outside the Operating Room. J Patient Sa…
  10. psnet.ahrq.gov/issue/registration-errors-among-patients-receiving-blood-transfusions-national-analysis-2008-2017
    March 18, 2020 - Study Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017. Citation Text: Vijenthira S, Armali C, Downie H, et al. Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017. Vox Sang. 2021;116…
  11. www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-practice-assessments.pdf
    June 02, 2025 - Job Aid: Practice Assessments and Surveys Primary Care Practice Facilitator Training Series 1 Job Aid: Practice Assessments and Surveys Overview Practice assessments and surveys are simple and non-threatening ways for a practice to gather information, generate ideas for improvements, and test and…
  12. psnet.ahrq.gov/issue/reducing-burden-surgical-harm-systematic-review-interventions-used-reduce-adverse-events
    June 21, 2016 - Review Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery. Citation Text: Howell A-M, Panesar S, Burns EM, et al. Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse eve…
  13. psnet.ahrq.gov/issue/report-information-technology-and-health-deficiencies-us-nursing-homes
    October 28, 2020 - Study A report of information technology and health deficiencies in U.S. nursing homes. Citation Text: Alexander GL, Madsen RW. A report of information technology and health deficiencies in U.S. nursing homes. J Patient Saf. 2021;17(6):e483-e489. doi:10.1097/pts.0000000000000390. Copy …
  14. www.ahrq.gov/teamstepps-program/curriculum/situation/tools/step.html
    June 01, 2023 - Tool: STEP STEP is a mnemonic tool that can help individuals monitor critical elements of a situation and the overall environment. It is suitable for use by teams supporting acutely ill patients in a hospital (e.g., an ICU patient the team hopes to wean off a ventilator as quickly as possible), for teams in lon…
  15. psnet.ahrq.gov/issue/effects-electronic-nursing-handover-patient-safety-general-non-covid-19-and-covid-19
    February 26, 2020 - Study The effects of electronic nursing handover on patient safety in the general (non-COVID-19) and COVID-19 intensive care units: a quasi-experimental study. Citation Text: Tataei A, Rahimi B, Afshar HL, et al. The effects of electronic nursing handover on patient safety in the general…
  16. psnet.ahrq.gov/issue/clinical-diagnoses-and-autopsy-findings-discrepancies-critically-ill-patients
    March 09, 2022 - Study Clinical diagnoses and autopsy findings: discrepancies in critically ill patients. Citation Text: Tejerina E, Esteban A, Fernández-Segoviano P, et al. Clinical diagnoses and autopsy findings: discrepancies in critically ill patients*. Crit Care Med. 2012;40(3):842-6. doi:10.1097/…
  17. psnet.ahrq.gov/issue/evaluation-and-comparison-errors-nursing-notes-created-online-and-offline-speech-recognition
    April 13, 2022 - Study Evaluation and comparison of errors on nursing notes created by online and offline speech recognition technology and handwritten: an interventional study. Citation Text: Peivandi S, Ahmadian L, Farokhzadian J, et al. Evaluation and comparison of errors on nursing notes created by o…
  18. psnet.ahrq.gov/issue/office-surgery-incidents-what-seven-years-florida-data-show-us
    August 19, 2009 - Study Office surgery incidents: what seven years of Florida data show us. Citation Text: Coldiron BM, Healy C, Bene NI. Office surgery incidents: what seven years of Florida data show us. Dermatol Surg. 2008;34(3):285-91; discussion 291-2. doi:10.1111/j.1524-4725.2007.34060.x. Copy C…
  19. psnet.ahrq.gov/issue/comparing-variability-ingredient-strength-and-dose-form-information-electronic-prescriptions
    March 20, 2024 - Study Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions. Citation Text: Lester CA, Flynn AJ, Marshall VD, et al. Comparing the variability of ingredient, strength, and dose form information fro…
  20. www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-p.html
    May 01, 2017 - Appendix P. Evaluating and Selecting Hand Hygiene Products - Implementation Guide Slide 1: Appendix P. Evaluating and Selecting Hand Hygiene Products Timothy Landers, Ph.D., R.N., CNP, CIC Assistant Professor, The Ohio State University College of Nursing Slide 2: Disclosures Dr. Landers receives sala…