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psnet.ahrq.gov/issue/understanding-procedural-violations-using-safety-i-and-safety-ii-case-community-pharmacies
February 06, 2019 - Study
Understanding procedural violations using Safety-I and Safety-II: the case of community pharmacies.
Citation Text:
Jones CEL, Phipps D, Ashcroft DM. Understanding procedural violations using Safety-I and Safety-II: The case of community pharmacies. Saf Sci. 2018;105:114-120. doi:10…
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psnet.ahrq.gov/issue/differentiating-between-detrimental-and-beneficial-interruptions-mixed-methods-study
May 03, 2017 - Study
Differentiating between detrimental and beneficial interruptions: a mixed-methods study.
Citation Text:
Myers RA, McCarthy MC, Whitlatch A, et al. Differentiating between detrimental and beneficial interruptions: a mixed-methods study. BMJ Qual Saf. 2016;25(11):881-888. doi:10.1136…
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psnet.ahrq.gov/issue/which-aspects-safety-culture-predict-incident-reporting-behavior-neonatal-intensive-care
June 15, 2011 - Study
Which aspects of safety culture predict incident reporting behavior in neonatal intensive care units? A multilevel analysis.
Citation Text:
Snijders C, Kollen BJ, van Lingen RA, et al. Which aspects of safety culture predict incident reporting behavior in neonatal intensive care …
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psnet.ahrq.gov/issue/drone-delivery-medications-review-landscape-and-legal-considerations
May 18, 2022 - Commentary
Emerging Classic
Drone delivery of medications: review of the landscape and legal considerations.
Citation Text:
Lin CA, Shah K, Mauntel LCC, et al. Drone delivery of medications: Review of the landscape and legal considerations. Am J Health Syst Phar…
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psnet.ahrq.gov/issue/using-incident-reporting-improve-patient-safety-conceptual-model
June 29, 2009 - Commentary
Using incident reporting to improve patient safety: a conceptual model.
Citation Text:
Pronovost PJ, Holzmueller CG, Young J, et al. Using Incident Reporting to Improve Patient Safety. J Patient Saf. 2008;3(1). doi:10.1097/pts.0b013e318030ca05.
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Format:
…
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psnet.ahrq.gov/issue/potentially-inappropriate-medication-use-and-healthcare-expenditures-us-community-dwelling
April 08, 2020 - Study
Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly.
Citation Text:
Fu AZ, Jiang JZ, Reeves JH, et al. Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly. Med Care. 2007;4…
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psnet.ahrq.gov/issue/nurses-relate-contributing-factors-involved-medication-errors
February 18, 2009 - Study
Nurses relate the contributing factors involved in medication errors.
Citation Text:
Tang F-I, Sheu S-J, Yu S, et al. Nurses relate the contributing factors involved in medication errors. J Clin Nurs. 2007;16(3):447-57.
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Format:
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psnet.ahrq.gov/issue/safe-enough-here-patients-expectations-and-experiences-feeling-safe-acute-psychiatric
January 23, 2017 - Study
'Safe enough in here?': Patients' expectations and experiences of feeling safe in an acute psychiatric inpatient ward.
Citation Text:
Stenhouse RC. 'Safe enough in here?': patients' expectations and experiences of feeling safe in an acute psychiatric inpatient ward. J Clin Nurs. 20…
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psnet.ahrq.gov/issue/multiprofessional-survey-protocol-use-intensive-care-unit
August 30, 2017 - Study
Multiprofessional survey of protocol use in the intensive care unit.
Citation Text:
LeBlanc JM, Kane-Gill SL, Pohlman AS, et al. Multiprofessional survey of protocol use in the intensive care unit. J Crit Care. 2012;27(6):738.e9-17. doi:10.1016/j.jcrc.2012.07.012.
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psnet.ahrq.gov/issue/strategies-reduce-patient-harm-infusion-associated-medication-errors-scoping-review
August 10, 2016 - Review
Strategies to reduce patient harm from infusion-associated medication errors: a scoping review.
Citation Text:
Wolf ZR. Strategies to Reduce Patient Harm From Infusion-Associated Medication Errors: A Scoping Review. J Infus Nurs. 2018;36(1):58-65. doi:10.1097/NAN.0000000000000263.…
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psnet.ahrq.gov/issue/frequency-and-type-situational-awareness-errors-contributing-death-and-brain-damage-closed
September 01, 2021 - Study
Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis.
Citation Text:
Schulz CM, Burden A, Posner KL, et al. Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Anal…
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psnet.ahrq.gov/issue/decade-health-information-technology-usability-challenges-and-path-forward
January 16, 2019 - Commentary
Emerging Classic
A decade of health information technology usability challenges and the path forward.
Citation Text:
Ratwani RM, Reider J, Singh H. A Decade of Health Information Technology Usability Challenges and the Path Forward. JAMA. 2019;321(8):…
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digital.ahrq.gov/track-2-implementation-issues-patient-safety-and-health-it
January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…
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digital.ahrq.gov/track-9-emerging-approaches-drive-change-healthcare
January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…
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digital.ahrq.gov/track-5-achieving-and-sustaining-improvements
January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…
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integrationacademy.ahrq.gov/sites/default/files/2025-07/MOUD_Playbook_Environmental_Scan_2025.pdf
January 01, 2025 - provider perspective, one of the primary challenges to sustaining care is the potential
difficulty in maintaining … providers who will accept it.34 Stigma, a fear of withdrawal symptoms, or disinterest in pursuing or
maintaining … • Flexibility in dosing, protocols, policies, and workflows for initiating and maintaining
buprenorphine
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www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary/obesity-in-adults-screening-and-counseling-2003
December 15, 2003 - Due to adverse event: 6/115
Fair
Placebo
-4.9 kg
Maintaining … self-directed behavior change, nutrition and physical activity education, and social support for making and maintaining
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/ZYao53-sqRb6oZzKzDmjjt
December 01, 2003 - 18/64
0% Due to adverse event: NR
–8.9 kg –4 kg < 0.001 Sibutramine: Fair
–4.9 kg Dropout: 148/352
Maintaining … self-directed behavior change,
nutrition and physical activity education, and social support for making and maintaining
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx
Spotlight
Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-insertion-notes.docx
April 01, 2022 - Central Venous Catheter Insertion Bundle Facilitator Notes
CLABSI Module:
Central Venous Catheter Insertion
Facilitator Guide
Slide Number and Image
This module, titled Central Venous Catheter Insertion, is part of the Agency for Healthcare Research and Quality’s Safety Program for Intensive Care Units (ICUs) t…