- 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Snow.pdf
January 01, 2010 - Use of the registry for health services research. … To err 
is human: building a safer health system. … Committee on Quality Health Care in America, 
Institute of Medicine. … Rockville, MD: Health and 
Human Services; 2001. 
5. The state of health care quality. … Department of Health and Human 
Services (HHS); 1999. 
10.
                                     
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-6-implementation-guide.pdf
June 02, 2025 - o Working with hospital or health system administration to create 
comparative data reports related to … • Case Study: Mount Carmel Health System—Cardiac Rehab Open Gym 
Q&A with Mt. … Carmel Health System, which implemented an Open Gym model. … • Case Study: Christiana Care Health System—Use Clinician Follow-up to Bolster Enrollment 
Q&A with … Christiana Care Health System, which uses "non-enrollment letters" to notify referring 
cardiologists
                                     
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Linzer.pdf
January 01, 2002 - Mental health was determined using the 12-item General Health Questionnaire 
(GHQ-12).24 In this scale … , and mental health. … Health Psychology 
1993;12:93–102. 
8. Weisman CS, Nathanson CA. … HSMHA 
Health Reports 1971;86:993–1003. 
10. Melville A. … The role of job satisfaction, job stress, mental 
and physical health.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-issuebrief-maternal-morbidity.pdf
September 01, 2021 - NYC Health + Hospitals/Jacobi 
NYC Health + Hospitals, Albert Einstein College of Medicine
Ariel de … Department of Health and Human Services. … Department of Health and Human Services. … Evaluate how health information 
technology, such as electronic health 
records, contributes to diagnostic … NYC Health.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-131-fullreport.pdf
April 05, 2017 - complicated by side 
effects caused by treatment or the illness itself or by increased social, emotional, and behavioral … Measure Topic – care in the most integrated setting: No.  
m. … Health plan*: Can compare quality of care among health plans. … or facility:** Can compare: (i) practice sites; (ii) medical or other 
professional groups; or (iii) integrated … health 
IT system?
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/continuing-ed/moc_sms.pdf
March 29, 2016 - • Ask patients about their health priorities and preferences. … • Collaboratively set health goals with patients. … • Listening to your patient’s health concerns and ideas. … goal, a first step in an action plan for better health. … /health-information/health-topics/Diabetes/4-steps-manage-diabetes/Pages/publicationdetail.aspx
http:
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-194-fullreport.pdf
April 01, 2019 - Measure Topic – care in the most integrated setting: No.  
m. … HealthCore owns 
and operates the HealthCore Integrated Research Database (HIRD), a longitudinal database … Health plan*: Can compare quality of care among health plans. … or facility:** Can compare: (i) practice sites; (ii) medical or other 
professional groups; or (iii) integrated … health 
IT system?
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-196-fullreport.pdf
January 01, 2020 - Measure Topic – care in the most integrated setting: No.  
m. … HealthCore owns 
and operates the HealthCore Integrated Research Database (HIRD), a longitudinal database … Health plan*: Can compare quality of care among health plans. … or facility:** Can compare: (i) practice sites; (ii) medical or other 
professional groups; or (iii) integrated … health 
IT system?
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Elder_18.pdf
February 19, 2008 - • Technology level (electronic health record, no EHR). … Handbook of human factors and ergonomics in health 
care and patient safety. … Qual Saf Health Care 2006; 15 (Suppl 1): i50-i58. 
3. … To err is human: 
Building a safer health system. … Qual Saf Health 
Care 2003; 12(Suppl 2): ii2-ii7. 
27. Bogner M.
                                     
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/icu-assessment-guide.pdf
April 01, 2022 - Playbook for Preventing CLABSI and CAUTI in ICU Setting 
o The Playbook demonstrates how CUSP can be integrated … Playbook for Preventing CLABSI and CAUTI in ICU Setting 
o The Playbook demonstrates how CUSP can be integrated … patterns of behavior that determine the 
commitment to, and the style and proficiency of, a unit's health … Leadership rounds to reduce health care-
associated infections.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/2025-02/singh-report.pdf
January 01, 2025 - DeBakey VA Medical Center, Houston, TX, Section of Health Services 
Research, Department of Medicine … Hermann Center for Healthcare Quality & Safety, School of 
Biomedical Informatics, University of Texas Health … 172 medical centers and 1138 outpatients on a comprehensive, in-house--
designed EHR that has been integrated … Improving Diagnosis in Health Care — The Next Imperative for Patient
Safety. … Improving diagnosis in health care.
3. Singh H, Graber ML, Hofer TP.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/delirium-1.pdf
March 01, 2020 - One-year health care costs associated with delirium in 
the elderly population. … Developing and implementing an integrated delirium 
prevention system of care: A theory driven, participatory … BMC Health Serv Res. 
2013;13:341. doi: 10.1186/1472-6963-13-341. 
23. … Implementation 
Themes/Findings 
Risk of Bias 
(High, 
Moderate, 
Low) 
Godfrey et 
al., 201321 
Integrated … [The] evolving conception of an 
integrated model of delirium 
prevention presented major 
implementation
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
April 22, 2004 - Key to 
Understanding Health Care Systems 
Ben-Tzion Karsh, Samuel J. … A hospital exists within a larger community health 
system. … To err 
is human: building a safer health system. … Medication 
errors observed in 36 health care facilities. … Qual Saf Health Care 2003;12(Suppl II):ii33–
ii38. 
44.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/012-blood-culture-practices-webinar.docx
October 01, 2024 - things, she helps them by informing them of an upcoming initiative to upgrade the hospital’s electronic health … Department of Health and Human Services.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Gavin.pdf
January 01, 2001 - the 
REAPS so that the rater will understand “leaning forward” as describing a 
postural (versus a behavioral … could be performed by a 
nonclinical person), consulting a therapist would preserve the safety and health … departments to address postural problems before they cause or 
exacerbate medical problems and jeopardize the health … University of South Florida, Department of Aging and Mental Health, Florida Mental Health Institute,
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/pharmacy/2015-report-part-1.pdf
January 01, 2015 - Department of Health and Human Services. … Introduction 
Patient safety is a critical component of health care quality. … the database community pharmacies (53 percent) were chain 
drugstores (local, regional, national) or integrated … health system pharmacies 
(non-hospital unit based) … half (53 percent) of database community pharmacies were chain drugstore 
(local, regional, national)/integrated
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/publications2/files/MeasureDx-guide.pdf
July 01, 2022 - Department of Health and Human 
Services. … Activities described here should be integrated with routine quality and 
safety activities of an organization … Tips for Implementation
An integrated EHR database provides a longitudinal 
view of the patient’s diagnostic … could be 
developed to identify patients who are at 
elevated risk of diagnostic safety events 
and integrated … Rand Health Q. 2017 Jun 19;6(3):1.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/handouts.html
September 01, 2017 - It is difficult to assemble the treatment history and understand other health issues that we need to
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/2025-04/newman-toker2-report.pdf
January 01, 2025 - Background 
Misdiagnosis is a major public health problem.12 In 2000, medical errors were estimated … behaviors,25,26 and to provide health information.27-29 
Occasionally, an explicit attempt has been … To err is human: building a safer health system. … Within health care hides massive, avoidable death toll. … Am JPublic Health. 2002;92(2):294-7. 
27. Bouhaddou O, Warner H.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/2024-07/mazor-report.pdf
January 01, 2024 - began to conduct outreach interviews on all units (with the exception of the 
labor and delivery and behavioral … To err is human : building a safer health system. … Committee on Quality of Health Care in America. … Health affairs. 2008;27(1):246-55. PMID: 18180501.
9. AHRQ. … Health expectations : an international journal of public participation in 
health care and health policy