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psnet.ahrq.gov/issue/building-cultures-high-reliability-lessons-high-reliability-organization-paradigm
September 05, 2018 - Review
Building cultures of high reliability: lessons from the high reliability organization paradigm.
Citation Text:
Sutcliffe KM. Building cultures of high reliability: lessons from the high reliability organization paradigm. Anesthesiol Clin. 2023;41(4):707-717. doi:10.1016/j.anclin.2…
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digital.ahrq.gov/2020-year-review/research-summary/strengthening-patient-engagement-improve-care-and-shared-decision-making
January 01, 2020 - Strengthening Patient Engagement to Improve Care and Shared Decision Making
Patient engagement in healthcare leads to improvements in safety, quality, and satisfaction of care. Digital healthcare tools can facilitate patient engagement via the use of patient portals, smartphones, and…
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psnet.ahrq.gov/issue/free-harm-accelerating-patient-safety-improvement-fifteen-years-after-err-human
November 15, 2016 - Book/Report
Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human.
Citation Text:
Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human. Boston, MA: National Patient Safety Foundation; 2015.
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psnet.ahrq.gov/issue/patient-safety-not-elective-debate-npsf-patient-safety-congress
March 18, 2019 - Commentary
Patient safety is not elective: a debate at the NPSF Patient Safety Congress.
Citation Text:
McTiernan P, Wachter R, Meyer GS, et al. Patient safety is not elective: a debate at the NPSF Patient Safety Congress. BMJ Qual Saf. 2015;24(2):162-6. doi:10.1136/bmjqs-2014-003429.
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psnet.ahrq.gov/issue/restorative-just-culture-exploration-enabling-conditions-successful-implementation
February 08, 2023 - Study
Restorative just culture: an exploration of the enabling conditions for successful implementation.
Citation Text:
Boskeljon-Horst L, Steinmetz V, Dekker SWA. Restorative just culture: an exploration of the enabling conditions for successful implementation. Healthcare (Basel). 2024;…
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psnet.ahrq.gov/issue/kaiser-permanentes-performance-improvement-system-part-4-creating-learning-organization
July 19, 2023 - Commentary
Kaiser Permanente's performance improvement system, part 4: creating a learning organization.
Citation Text:
Schilling L, Dearing JW, Staley P, et al. Kaiser Permanente's performance improvement system, Part 4: Creating a learning organization. Jt Comm J Qual Patient Saf. 2011…
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psnet.ahrq.gov/issue/textbook-rapid-response-systems-concept-and-implementation
September 30, 2010 - Book/Report
Textbook of Rapid Response Systems: Concept and Implementation.
Citation Text:
Textbook Of Rapid Response Systems: Concept And Implementation. (DeVita MA, ed.). Springer; 2025. ISBN 9783031679513.
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Google Scholar BibTeX EndNote X3 XML EndNo…
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digital.ahrq.gov/2018-year-review/research-summary/simple-mobile-application-key-patient-engagement-reporting-and
January 01, 2018 - A Simple Mobile Application is Key to Patient Engagement in Reporting and Monitoring of Asthma Symptoms
Key Finding and Impact:
A simple app, designed with input from patients, resulted in 92 percent of patients continuing to report their asthma outcomes at the end of the study. A tool like this simple app ma…
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psnet.ahrq.gov/issue/governing-safety-artificial-intelligence-healthcare
February 28, 2024 - Review
Emerging Classic
Governing the safety of artificial intelligence in healthcare.
Citation Text:
Macrae C. Governing the safety of artificial intelligence in healthcare. BMJ Qual Saf. 2019;28(6):495-498. doi:10.1136/bmjqs-2019-009484.
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digital.ahrq.gov/2019-year-review/research-summary/supporting-clinicians-improve-decision-making-and-patients-care
January 01, 2019 - Supporting Clinicians to Improve Decision Making and Patients' Care
Research funded by AHRQ’s Digital Healthcare Research Program aims to support clinicians and other healthcare professionals in providing health services. In 2019, total program investment in research to support clinical …
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digital.ahrq.gov/organization/university-utah
January 01, 2023 - University of Utah
An Age-Friendly Learning Healthcare System: A Transformative Digital Solution for Geriatrics Clinics
Description
The study will create and implement digital tools using the SMART on FHIR framework to support Age-Friendly care in clinical practice and institu…
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digital.ahrq.gov/ahrq-funded-projects/development-and-implementation-remote-telehealth-user-reported-cancer
September 30, 2023 - Development and Implementation of the REmote Telehealth User-Reported caNcer Surveillance (RETURNS) Program for Lung Cancer
Project Description
The ability to remotely collect and review signs and symptoms of lung cancer recurrence using patient-reported outcomes and results of…
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psnet.ahrq.gov/issue/guide-patient-and-family-engagement-hospital-quality-and-safety
December 24, 2008 - Multi-use Website
Guide to Patient and Family Engagement in Hospital Quality and Safety.
Citation Text:
Guide to Patient and Family Engagement in Hospital Quality and Safety. Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
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digital.ahrq.gov/program-overview/research-stories/evaluation-scaling-acceptable-cds-scaled-approach-interoperable
January 01, 2023 - Evaluation of the SCaling AcceptabLE cDs (SCALED) Approach of Interoperable Clinical Decision Support for Venous Thromboembolism Prevention
Theme:
Optimizing Care Delivery for Clinicians
Subtheme:
Scaling Effective and Interoperable CDS to Improve Care and Decision Making
A methodology for…
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psnet.ahrq.gov/issue/ambiguity-and-workarounds-contributors-medical-error
December 23, 2008 - Commentary
Ambiguity and workarounds as contributors to medical error.
Citation Text:
Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med. 2005;142(8):627-630.
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psnet.ahrq.gov/issue/sbar-shared-mental-model-improving-communication-between-clinicians
January 02, 2017 - Study
SBAR: a shared mental model for improving communication between clinicians.
Citation Text:
Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32(3):167-75.
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psnet.ahrq.gov/issue/applying-human-centered-design-thinking-enhance-safety-or
May 25, 2016 - Commentary
Applying human-centered design thinking to enhance safety in the OR.
Citation Text:
Criscitelli T, Goodwin W. Applying Human-Centered Design Thinking to Enhance Safety in the OR. AORN J. 2017;105(4):408-412. doi:10.1016/j.aorn.2017.02.004.
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D…
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digital.ahrq.gov/health-care-theme/adverse-events
January 01, 2023 - Adverse Events
Implementation of DDInteract: A Shared Decision Making Tool for Anticoagulant Drug-Drug Interactions
Description
This research will implement, evaluate, and disseminate DDInteract, a shared decision making clinical decision support tool that aims to reduce harm …
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psnet.ahrq.gov/issue/using-automated-risk-assessment-report-identify-patients-risk-clinical-deterioration
February 15, 2017 - Commentary
Using an automated risk assessment report to identify patients at risk for clinical deterioration.
Citation Text:
Whittington J, White R, Haig KM, et al. Using an automated risk assessment report to identify patients at risk for clinical deterioration. Jt Comm J Qual Patient S…
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psnet.ahrq.gov/issue/coaching-debriefer-peer-coaching-improve-debriefing-quality-simulation-programs
July 31, 2019 - Commentary
Coaching the debriefer: peer coaching to improve debriefing quality in simulation programs.
Citation Text:
Cheng A, Grant V, Huffman J, et al. Coaching the Debriefer: Peer Coaching to Improve Debriefing Quality in Simulation Programs. Simul Healthc. 2017;12(5):319-325. doi:10.…