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effectivehealthcare.ahrq.gov/sites/default/files/related_files/clinical-care-protocol.pdf
January 01, 2024 - Making Healthcare Safer IV: Programs for Responding to Harms Experienced by Patients during Clinical Care
Evidence-based Practice Center Rapid Review Protocol
Project Title: Making Healthcare Safer IV: Programs for Responding to
Harms Experienced by Patients during Clinical Care
Review Question…
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pso.ahrq.gov/sites/default/files/wysiwyg/ai-healthcare-safety-program.pdf
July 01, 2025 - Artificial Intelligence (AI) in Healthcare Safety Program: October 2024 Update
1
Artificial Intelligence (AI) in Healthcare
Safety Program – October 2024 Update
Overview
In response to Executive Order 14110, Safe, Secure, and Trustworthy Development and Use of Artificial
Intelligence (“EO 14110”), HHS establish…
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - Miscommunication During the Interhospital Transport of a Critically Ill Child
Citation Text:
Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human …
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/105-what-are-the-4-es-notes.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
What Are the 4 Es?
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
Slide Title and Commentary
Slide Number and Slide
What Are the 4 Es?
SAY:
This presentation reviews the 4 Es, a framework to guide the implementation…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Ramanujam.pdf
January 01, 2003 - Making a Case for Organizational Change in Patient Safety Initiatives
455
Making a Case for Organizational
Change in Patient Safety Initiatives
Rangaraj Ramanujam, Donna J. Keyser, Carl A. Sirio
Abstract
Objectives: Widespread organizational change is indispensable for significantly
improved patient safety…
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psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
October 24, 2018 - Study
Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.
Citation Text:
Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health A…
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psnet.ahrq.gov/issue/massive-open-online-course-mooc-learning-builds-capacity-and-improves-competence-patient
October 14, 2020 - Study
Massive open online course (MOOC) learning builds capacity and improves competence for patient safety among global learners: a prospective cohort study.
Citation Text:
Gleason KT, Commodore-Mensah Y, Wu AW, et al. Massive open online course (MOOC) learning builds capacity and impro…
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psnet.ahrq.gov/issue/incidence-nature-and-causes-avoidable-significant-harm-primary-care-england-retrospective
November 13, 2019 - Study
Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.
Citation Text:
Avery AJ, Sheehan C, Bell BG, et al. Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note …
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psnet.ahrq.gov/issue/cluster-randomized-trial-two-implementation-strategies-deliver-audit-and-feedback-equipped
September 01, 2018 - Study
A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program.
Citation Text:
Vaughan CP, Burningham Z, Kelleher JL, et al. A cluster‐randomized trial of two implementation strategies to deliver audit and feedbac…
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psnet.ahrq.gov/issue/impact-closed-loop-electronic-prescribing-and-administration-system-prescribing-errors
November 13, 2009 - Study
The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study.
Citation Text:
Franklin BD, O'Grady K, Donyai P, et al. The impact of a closed-loop electronic prescribing and admin…
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psnet.ahrq.gov/issue/direct-observation-depression-screening-identifying-diagnostic-error-and-improving-accuracy
December 08, 2021 - Study
Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients.
Citation Text:
Schwartz A, Peskin S, Spiro A, et al. Direct observation of depression screening: identifying diagnostic error and improving acc…
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psnet.ahrq.gov/issue/discrepancy-between-emergency-department-admission-diagnosis-and-hospital-discharge-diagnosis
December 08, 2021 - Study
Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality.
Citation Text:
Bastakoti M, Muhailan M, Nassar A, et al. Discrepancy between emergency department adm…
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psnet.ahrq.gov/issue/strengths-and-weaknesses-diagnostic-process-endometriosis-patients-perspective-focus-group
March 06, 2019 - Study
Strengths and weaknesses in the diagnostic process of endometriosis from the patients' perspective: a focus group study.
Citation Text:
van der Zanden M, de Kok L, Nelen WLDM, et al. Strengths and weaknesses in the diagnostic process of endometriosis from the patients’ perspective:…
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psnet.ahrq.gov/issue/national-study-links-nurses-physical-and-mental-health-medical-errors-and-perceived-worksite
July 14, 2021 - Study
A national study links nurses' physical and mental health to medical errors and perceived worksite wellness.
Citation Text:
Melnyk BM, Orsolini L, Tan A, et al. A National Study Links Nurses' Physical and Mental Health to Medical Errors and Perceived Worksite Wellness. J Occup Envi…
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psnet.ahrq.gov/issue/implementing-medication-reconciliation-outpatient-pediatrics
September 23, 2020 - Study
Implementing medication reconciliation in outpatient pediatrics.
Citation Text:
Rappaport DI, Collins B, Koster A, et al. Implementing medication reconciliation in outpatient pediatrics. Pediatrics. 2011;128(6):e1600-7. doi:10.1542/peds.2011-0993.
Copy Citation
Format:
…
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psnet.ahrq.gov/issue/structured-approach-ehr-surveillance-diagnostic-error-acute-care-exploratory-analysis-two
October 16, 2024 - Study
A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.
Citation Text:
Malik MA, Motta-Calderon D, Piniella N, et al. A structured approach to EHR surveillance of diagnostic error in acute car…
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digital.ahrq.gov/ahrq-funded-projects/massachusetts-quality-e-measure-validation-study/annual-summary/2011
January 01, 2011 - Massachusetts Quality E-Measure Validation Study - 2011
Project Name
Massachusetts Quality e-Measure Validation Study
Principal Investigator
Schneider, Eric
Organization
RAND Corporation
Funding Mechanism
RFA: HS07-002: Ambulatory and Safety Quality Program: Enablin…
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digital.ahrq.gov/ahrq-funded-projects/massachusetts-quality-e-measure-validation-study/annual-summary/2010
January 01, 2010 - Massachusetts Quality E-Measure Validation Study - 2010
Project Name
Massachusetts Quality e-Measure Validation Study
Principal Investigator
Schneider, Eric
Organization
RAND Corporation
Funding Mechanism
RFA: HS07-002: Ambulatory and Safety Quality Program: Enablin…
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psnet.ahrq.gov/issue/differences-between-methods-detecting-medication-errors-secondary-analysis-medication
December 18, 2019 - Study
Emerging Classic
Differences between methods of detecting medication errors: a secondary analysis of medication administration errors using incident reports, the Global Trigger Tool method, and observations.
Citation Text:
Härkänen M, Turunen H, Vehviläine…
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psnet.ahrq.gov/issue/unscheduled-radiologic-examination-orders-electronic-health-record-novel-resource-targeting
March 30, 2022 - Study
Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology.
Citation Text:
Lacson R, Healey MJ, Cochon LR, et al. Unscheduled Radiologic Examination Orders in the Electronic Health Record: A No…