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psnet.ahrq.gov/issue/systematic-assessment-culture-review-tool-assess-errors-clinical-microbiology-laboratory
November 16, 2022 - Study
Systematic assessment of culture review as a tool to assess errors in the clinical microbiology laboratory.
Citation Text:
Goodyear N, Ulness BK, Prentice JL, et al. Systematic assessment of culture review as a tool to assess errors in the clinical microbiology laboratory. Arch P…
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psnet.ahrq.gov/issue/minimizing-electronic-health-record-patient-note-mismatches
December 27, 2014 - Study
Minimizing electronic health record patient–note mismatches.
Citation Text:
Wilcox AB, Chen Y-H, Hripcsak G. Minimizing electronic health record patient-note mismatches. J Am Med Inform Assoc. 2011;18(4):511-4. doi:10.1136/amiajnl-2010-000068.
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psnet.ahrq.gov/issue/patient-safety-operating-room-part-1-and-part-2
October 19, 2022 - Review
Patient safety in the operating room—part 1 and part 2.
Citation Text:
Poore SO, Sillah NM, Mahajan AY, et al. Patient safety in the operating room: II. Intraoperative and postoperative. Plast Reconstr Surg. 2012;130(5):1048-58. doi:10.1097/PRS.0b013e318267d531.
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psnet.ahrq.gov/issue/lancet-commission-lessons-future-covid-19-pandemic
January 12, 2022 - Commentary
The Lancet Commission on lessons for the future from the COVID-19 pandemic.
Citation Text:
Sachs JD, Karim SSA, Aknin L, et al. The Lancet Commission on lessons for the future from the COVID-19 pandemic. Lancet. 2022;400(10359):1224-1280. doi:10.1016/s0140-6736(22)01585-9.
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www.ahrq.gov/news/newsroom/case-studies/202301.html
October 01, 2024 - Ohio Veterans’ Facility Relied on AHRQ Resource to Develop Diabetes Initiative
Search All Impact Case Studies
March 2023
The Dayton (Ohio) Veterans Affairs (VA) Medical Center facility has adopted AHRQ’s SHARE Approach as part of the U.S. Department of Veterans Affairs' national Hypoglycemic Safety Initia…
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digital.ahrq.gov/organization/medstar-research-institute
January 01, 2023 - MedStar Health Research Institute
Guiding the Safe and Effective Integration of Ambient Digital Scribes into Primary Care
Description
This study will develop a prototype guide for the safe and effective integration of ambient digital scribes into primary care, providing insigh…
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digital.ahrq.gov/location/usa-md-hyattsville
January 01, 2023 - USA, MD, Hyattsville
Guiding the Safe and Effective Integration of Ambient Digital Scribes into Primary Care
Description
This study will develop a prototype guide for the safe and effective integration of ambient digital scribes into primary care, providing insights into how t…
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psnet.ahrq.gov/submit-case-landing
March 25, 2025 - Breadcrumb
Home
Training and Education
WebM&M: Case Studies
WebM&M Case Submission
PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential …
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psnet.ahrq.gov/issue/afraid-hospital-parental-concern-errors-during-childs-hospitalization
April 21, 2011 - Study
Classic
Afraid in the hospital: parental concern for errors during a child's hospitalization.
Citation Text:
Tarini BA, Lozano P, Christakis DA. Afraid in the hospital: parental concern for errors during a child's hospitalization. J Hosp Med. 2009;41(9):…
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psnet.ahrq.gov/issue/health-care-consumers-inclination-engage-selected-patient-safety-practices-survey-adults
March 03, 2011 - Study
Health care consumers' inclination to engage in selected patient safety practices: a survey of adults in Pennsylvania.
Citation Text:
Marella WM, Finley E, Thomas AD, et al. Health Care Consumers' Inclination to Engage in Selected Patient Safety Practices. J Patient Saf. 2008;3(4…
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psnet.ahrq.gov/issue/low-literacy-impairs-comprehension-prescription-drug-warning-labels
January 21, 2009 - Study
Low literacy impairs comprehension of prescription drug warning labels.
Citation Text:
Davis TC, Wolf MS, Bass PF, et al. Low literacy impairs comprehension of prescription drug warning labels. J Gen Intern Med. 2006;21(8):847-51.
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digital.ahrq.gov/ahrq-funded-projects/past-initiatives/privacy-and-security-project
January 01, 2023 - Privacy and Security Project (2005-2007)
The Privacy and Security Project
RTI International has subcontracted with 33 states and 1 territory to create the Health Information Security and Privacy Collaboration (HISPC). These subcontractors have leveraged input from state leadership and a br…
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psnet.ahrq.gov/issue/anesthetic-mishaps-breaking-chain-accident-evolution
April 08, 2011 - Commentary
Classic
Anesthetic mishaps: breaking the chain of accident evolution.
Citation Text:
Gaba DM, Maxwell M, DeAnda A. Anesthetic mishaps: breaking the chain of accident evolution. Anesthesiology. 1987;66(5):670-6.
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psnet.ahrq.gov/issue/evaluation-design-and-structure-electronic-medication-labels-improve-patient-health-knowledge
October 16, 2024 - Review
Evaluation of the design and structure of electronic medication labels to improve patient health knowledge and safety: a systematic review.
Citation Text:
Saif S, Bui TTT, Srivastava G, et al. Evaluation of the design and structure of electronic medication labels to improve patien…
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hcup-us.ahrq.gov/db/vars/discwt_u/nisnote.jsp
September 01, 2008 - Healthcare Cost and Utilization Project (HCUP) NIS Notes
An official website of the Department of Health & Human Services
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Careers
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Espanol
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hcup-us.ahrq.gov/db/vars/drg_nopoa/nisnote.jsp
September 01, 2008 - Healthcare Cost and Utilization Project (HCUP) NIS Notes
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contact Us
Espanol
FAQs…
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psnet.ahrq.gov/issue/checking-all-boxes-checklist-when-and-how-use-checklists-effectively
June 29, 2022 - Commentary
Checking all the boxes: a checklist for when and how to use checklists effectively.
Citation Text:
Alfred M, Barg-Walkow LH, Keebler JR, et al. Checking all the boxes: a checklist for when and how to use checklists effectively. BMJ Qual Saf. 2024;33(10):673-681. doi:10.1136/bm…
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psnet.ahrq.gov/issue/adaptation-and-implementation-who-safe-childbirth-checklist-around-world
March 17, 2021 - Study
Adaptation and implementation of the WHO Safe Childbirth Checklist around the world.
Citation Text:
Molina RL, Benski A-C, Bobanski L, et al. Adaptation and implementation of the WHO Safe Childbirth Checklist around the world. Implement Sci Commun. 2021;2(1):76. doi:10.1186/s43058-…
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psnet.ahrq.gov/issue/clinical-case-electronic-health-record-drug-alert-fatigue-consequences-patient-outcome
August 02, 2023 - Commentary
A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.
Citation Text:
Carspecken W, Sharek PJ, Longhurst CA, et al. A clinical case of electronic health record drug alert fatigue: consequences for patient outcome. Pediatrics. 2013;131…
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psnet.ahrq.gov/issue/mortality-and-morbidity-rounds-mmr-pathology-relative-contribution-cognitive-bias-vs-systems
May 18, 2022 - Study
Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error.
Citation Text:
Eichbaum Q, Adkins B, Craig-Owens L, et al. Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias…