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psnet.ahrq.gov/node/41159/psn-pdf
September 29, 2017 - A nurse-led approach to developing and implementing a
collaborative count policy.
September 29, 2017
Norton EK, Micheli AJ, Gedney J, et al. A nurse-led approach to developing and implementing a
collaborative count policy. AORN J. 2012;95(2):222-7. doi:10.1016/j.aorn.2011.11.009.
https://psnet.ahrq.gov/issue/nurse…
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psnet.ahrq.gov/node/41177/psn-pdf
February 29, 2012 - A study of innovative patient safety education.
February 29, 2012
Smith SD, Henn P, Gaffney R, et al. A study of innovative patient safety education. Clin Teach.
2012;9(1):37-40. doi:10.1111/j.1743-498X.2011.00484.x.
https://psnet.ahrq.gov/issue/study-innovative-patient-safety-education
This educational interventi…
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psnet.ahrq.gov/node/865819/psn-pdf
May 08, 2024 - Focus on HARM (Harmonizing Accountability in
Reporting and Monitoring).
May 8, 2024
National Quality Forum.
https://psnet.ahrq.gov/issue/focus-harm-harmonizing-accountability-reporting-and-monitoring
Strong incident reporting systems are a foundational component for understanding preventable health care
error. Th…
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psnet.ahrq.gov/node/42330/psn-pdf
June 12, 2013 - Creating a culture of safety in the emergency department:
the value of teamwork training.
June 12, 2013
Jones F, Podila P, Powers C. Creating a culture of safety in the emergency department: the value of
teamwork training. J Nurs Adm. 2013;43(4):194-200. doi:10.1097/NNA.0b013e31828958cd.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/44109/psn-pdf
November 06, 2015 - Safer Clinical Systems.
November 6, 2015
London, UK: Health Foundation.
https://psnet.ahrq.gov/issue/safer-clinical-systems
This Web site highlights the work of a United Kingdom initiative launched in 2008 to apply safety
improvement tactics from high-risk industries to care services. The program engages teams to …
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psnet.ahrq.gov/node/48154/psn-pdf
July 31, 2019 - Learn Not Blame.
July 31, 2019
Doctors' Association UK.
https://psnet.ahrq.gov/issue/learn-not-blame
This website provides information about a National Health Service (NHS) campaign to shift response to
errors from blame to an approach that embraces fairness, openness, learning, and patient and health care
profes…
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psnet.ahrq.gov/node/42158/psn-pdf
April 03, 2013 - Long-term effects of a perioperative safety checklist from
the viewpoint of personnel.
April 3, 2013
Böhmer AB, Kindermann P, Schwanke U, et al. Long-term effects of a perioperative safety checklist from
the viewpoint of personnel. Acta Anaesthesiol Scand. 2013;57(2):150-7. doi:10.1111/aas.12020.
https://psnet.ahr…
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psnet.ahrq.gov/node/40835/psn-pdf
October 12, 2011 - Work system design for patient safety: the SEIPS model.
October 12, 2011
Carayon P, Schoofs Hundt A, Karsh B-T, et al. Work system design for patient safety: the SEIPS model.
Qual Saf Health Care. 2006;15(suppl 1):i50-i58. doi:10.1136/qshc.2005.015842.
https://psnet.ahrq.gov/issue/work-system-design-patient-safety-…
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psnet.ahrq.gov/node/35984/psn-pdf
January 02, 2017 - The clinical transformation of Ascension Health:
eliminating all preventable injuries and deaths.
January 2, 2017
Pryor DB, Tolchin SF, Hendrich A, et al. The clinical transformation of Ascension Health: eliminating all
preventable injuries and deaths. Jt Comm J Qual Patient Saf. 2006;32(6):299-308.
https://psnet.…
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psnet.ahrq.gov/node/43382/psn-pdf
September 17, 2014 - Using improvement science methods to increase
accuracy of surgical consents.
September 17, 2014
Mercurio P, Ellis AS, Schoettker PJ, et al. Using improvement science methods to increase accuracy of
surgical consents. AORN J. 2014;100(1):42-53. doi:10.1016/j.aorn.2013.07.023.
https://psnet.ahrq.gov/issue/using-impr…
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psnet.ahrq.gov/node/846766/psn-pdf
March 29, 2023 - The prisoner.
March 29, 2023
Kent S. NJ.com. March 12, 2023.
https://psnet.ahrq.gov/issue/prisoner
Heuristics, uncertainty, and bias are contributors to diagnostic error, overuse, and treatment delay. This
story describes the care experience of an adolescent patient whose rare immune system condition was
initiall…
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www.ahrq.gov/funding/process/study-section/index.html
February 01, 2023 - Study Sections for Scientific Peer Review
The Agency for Healthcare Research and Quality (AHRQ) has one chartered Health Services Research Initial Review Group (IRG) responsible for the peer review of grant applications submitted for study section review. This IRG comprises four subcommittees or study sections,…
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psnet.ahrq.gov/node/72863/psn-pdf
March 17, 2021 - 7 ways to prevent medical errors.
March 17, 2021
Caceres V. US News World Report. March 1, 2021.
https://psnet.ahrq.gov/issue/7-ways-prevent-medical-errors
Patients and families have an important role in reducing potential for error and harm. This article highlights
a set of tactics for patients to enhan…
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psnet.ahrq.gov/node/37014/psn-pdf
September 15, 2011 - Medication safety messages for patients via the web
portal: the MedCheck intervention.
September 15, 2011
Weingart SN, Hamrick HE, Tutkus S, et al. Medication safety messages for patients via the web portal: the
MedCheck intervention. Int J Med Inform . 2008;77(3):161-168.
https://psnet.ahrq.gov/issue/medication-s…
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psnet.ahrq.gov/node/45672/psn-pdf
January 01, 2025 - Healthcare Simulation Dictionary, Third Edition.
December 10, 2024
Lioce L, Lopreiato J, Anderson M, et al, eds and the Terminology and Concepts Working Group. Rockville,
MD: Agency for Healthcare Research and Quality; January 2025. AHRQ Publication No. 24-0077.
https://psnet.ahrq.gov/issue/healthcare-simulation-di…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/ace-inhibitor-arb-2007_research-2007-1.pdf
January 01, 2007 - Microsoft Word - Comp Eff 10.doc
This report is based on research conducted by the Duke Evidence-based Practice Center
(EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville,
MD (Contract No. 290-02-0025). The findings and conclusions in this do…
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs020693-wexler-final-report-2014.pdf
January 01, 2014 - Use of HIT to Increase Primary Care Access in Medicaid Patients - Final Report
TITLE PAGE
Title of Project
Use of HIT to Increase Primary Care Access in Medicaid Patients
Principle Investigator and Team Members
PI: Randell K Wexler, MD, MPH
Co-I: Ann Scheck McAlea…
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digital.ahrq.gov/sites/default/files/docs/publication/r21hs021581-goodney-final-report-2015.pdf
January 01, 2015 - Leveraging Health Information Technology to Avoid Unnecessary Asymptomatic Carotid Revascularization - Final Report
1. Title Page:
Title: Leveraging Health IT to Avoid Unnecessary Asymptomatic Carotid Revascularization
Principal Investigator: Philip P. Goodney, MD, MS
Organizati…
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs015409-overhage-final-report-2009.pdf
January 01, 2009 - Title Page
Grant Final Report
Grant ID: R01 HS 015409
Value of Health Information Exchange in
Ambulatory Care
Inclusive dates: 09/01/04 - 09/31/09
Principal Investigator:
J. Marc Overhage, MD, PhD; Director, Regenstrief Institute Medical Informatics; Regenstrief
Professor of Medicine,…
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psnet.ahrq.gov/node/865778/psn-pdf
May 29, 2024 - Navigating Complications: The Unintended Journey of a
Guidewire During Dialysis Catheter Placement
May 29, 2024
Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis
Catheter Placement. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-complications-unint…