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psnet.ahrq.gov/issue/dissecting-communication-barriers-healthcare-path-enhancing-communication-resiliency
July 12, 2023 - Commentary
Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety.
Citation Text:
Guttman OT, Lazzara EH, Keebler JR, et al. Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resilien…
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psnet.ahrq.gov/issue/patients-views-adverse-events-primary-and-ambulatory-care-systematic-review-assess-methods
December 18, 2017 - Review
Patients' views of adverse events in primary and ambulatory care: a systematic review to assess methods and the content of what patients consider to be adverse events.
Citation Text:
Lang S, Garrido MV, Heintze C. Patients' views of adverse events in primary and ambulatory care: a…
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www.ahrq.gov/news/newsroom/case-studies/cquips0901.html
October 01, 2014 - New York City Uses AHRQ Patient Safety Culture Survey to Reduce Patient Harm
Search All Impact Case Studies
November 2008
The New York City Health and Hospitals Corporation (HHC) has integrated the use of AHRQ's Hospital Survey on Patient Safety Culture as a core component of its corporate-wide patient sa…
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psnet.ahrq.gov/issue/developing-health-care-organizations-pursue-learning-and-exploration-diagnostic-excellence
October 28, 2020 - Commentary
Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan.
Citation Text:
Singh H, Upadhyay DK, Torretti D. Developing Health Care Organizations That Pursue Learning and Exploration of Diagnostic Excellence: An Action Pl…
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digital.ahrq.gov/ncpdp
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 It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work.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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psnet.ahrq.gov/issue/reducing-risk-and-promoting-patient-safety-nih-intramural-clinical-research-draft-report
November 18, 2020 - Book/Report
Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report.
Citation Text:
Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report. The Clinical Center Working Group Report to the Advisory Committee to the…
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psnet.ahrq.gov/issue/literacy-and-misunderstanding-prescription-drug-labels
September 17, 2010 - Study
Classic
Literacy and misunderstanding prescription drug labels.
Citation Text:
Davis TC, Wolf MS, Bass PF, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006;145(12):887-94.
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psnet.ahrq.gov/issue/realist-synthesis-intentional-rounding-hospital-wards-exploring-evidence-what-works-whom-what
March 01, 2023 - Review
Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumstances and why.
Citation Text:
Sims S, Leamy M, Davies N, et al. Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what …
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psnet.ahrq.gov/issue/impact-interruptions-distractions-and-cognitive-load-procedure-failures-and-medication
March 02, 2012 - Study
Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors.
Citation Text:
Thomas L, Donohue-Porter P, Fishbein JS. Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administratio…
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psnet.ahrq.gov/issue/nurses-perceived-skills-and-attitudes-about-updated-safety-concepts-impact-medication
January 03, 2017 - Study
Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices.
Citation Text:
Armstrong GE, Dietrich M, Norman L, et al. Nursesʼ Perceived Skills and Attitudes About Updated Safety Concepts. J Nurs Care Qual. 2016;32(…
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www.ahrq.gov/talkingquality/plan/your-audience/index.html
December 01, 2022 - Identify the Audience for Your Healthcare Quality Report
Before doing anything else, you need to consider your audience:
For whom are you creating this report?
What do they want to know?
What will they do with the information?
First Priority: The Primary Audience
The group you are trying to reach …
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integrationacademy.ahrq.gov/news-and-events/news/opioid-epidemic-and-covid-19-pandemic-deepening-disparities
December 23, 2020 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
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Integrating Behavioral Health & Primary Care
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psnet.ahrq.gov/issue/patients-and-physicians-attitudes-regarding-disclosure-medical-errors
March 21, 2017 - Study
Classic
Patients' and physicians' attitudes regarding the disclosure of medical errors.
Citation Text:
Gallagher TH, Waterman AD, Ebers AG, et al. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-7.
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psnet.ahrq.gov/issue/problem-using-patient-complaints-improvement
February 20, 2019 - Commentary
The problem with using patient complaints for improvement.
Citation Text:
de Vos MS, Hamming JF, van de Mheen PJM-. The problem with using patient complaints for improvement. BMJ Qual Saf. 2018;27(9):758-762. doi:10.1136/bmjqs-2017-007463.
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psnet.ahrq.gov/issue/systemic-failures-nursing-home-care-scoping-study
July 17, 2013 - Review
Systemic failures in nursing home care--a scoping study.
Citation Text:
Sturmberg JP, Gainsford L, Goodwin N, et al. Systemic failures in nursing home care—A scoping study. J Eval Clin Pract. 2024. doi:10.1111/jep.13961.
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digital.ahrq.gov/ahrq-funded-projects/colorado-associated-community-health-information-exchange-cachie
January 01, 2023 - Colorado Associated Community Health Information Exchange (CACHIE)
Project Final Report ( PDF , 644.33 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the v…
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psnet.ahrq.gov/issue/systematic-proactive-risk-assessment-hazards-surgical-wards-quantitative-study
August 15, 2013 - Study
A systematic proactive risk assessment of hazards in surgical wards: a quantitative study.
Citation Text:
Anderson O, Brodie A, Vincent CA, et al. A systematic proactive risk assessment of hazards in surgical wards: a quantitative study. Ann Surg. 2012;255(6):1086-92. doi:10.1097…
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psnet.ahrq.gov/issue/potential-uses-ai-perioperative-nursing-handoffs-qualitative-study
September 01, 2021 - Study
Potential uses of AI for perioperative nursing handoffs: a qualitative study.
Citation Text:
King CR, Shambe A, Abraham J. Potential uses of AI for perioperative nursing handoffs: a qualitative study. JAMIA Open. 2023;6(1):ooaf015. doi:10.1093/jamiaopen/ooad015.
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psnet.ahrq.gov/issue/long-term-sustainability-and-adaptation-i-pass-handovers
September 09, 2020 - Study
Long-term sustainability and adaptation of I-PASS handovers.
Citation Text:
Ryan SL, Logan M, Liu X, et al. Long-term sustainability and adaptation of I-PASS handovers. Jt Comm J Qual Patient Saf. 2023;19(12):689-697. doi:10.1016/j.jcjq.2023.07.007.
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psnet.ahrq.gov/issue/patient-engagement-health-care-safety-overview-mixed-quality-evidence
October 21, 2020 - Review
Emerging Classic
Patient engagement in health care safety: an overview of mixed-quality evidence.
Citation Text:
Sharma AE, Rivadeneira NA, Barr-Walker J, et al. Patient Engagement In Health Care Safety: An Overview Of Mixed-Quality Evidence. Health Aff (…