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  1. Using multidisciplinary rounds to improve patient safety through venous thromboembolism prevention awareness. | PSNet

    psnet.ahrq.gov/issue/using-multidisciplinary-rounds-improve-patient-safety-through-venous-thromboembolism
    April 20, 2016 - Study Using multidisciplinary rounds to improve patient safety through venous thromboembolism prevention awareness. Citation Text: Karasin B, Maund C. Using Multidisciplinary Rounds to Improve Patient Safety Through Venous Thromboembolism Prevention Awareness. Jt Comm J Qual Patient Saf.…

  2. Orienting frames and private routines: the role of cultural process in critical care safety. | PSNet

    psnet.ahrq.gov/issue/orienting-frames-and-private-routines-role-cultural-process-critical-care-safety
    December 31, 2014 - Study Orienting frames and private routines: the role of cultural process in critical care safety. Citation Text: Hazlehurst B, McMullen C. Orienting frames and private routines: the role of cultural process in critical care safety. Int J Med Inform. 2007;76 Suppl 1:S129-35. Copy Cit…

  3. Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages. | PSNet

    psnet.ahrq.gov/issue/safe-handling-concentrated-electrolyte-products-outsourcing-facilities-during-critical-drug
    December 15, 2021 - Press Release/Announcement Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages. Citation Text: Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages. National Alert Network. …

  4. The checklist--a tool for error management and performance improvement. | PSNet

    psnet.ahrq.gov/issue/checklist-tool-error-management-and-performance-improvement
    June 29, 2011 - Review The checklist--a tool for error management and performance improvement. Citation Text: Hales BM, Pronovost P. The checklist--a tool for error management and performance improvement. J Crit Care. 2006;21(3):231-5. Copy Citation Format: Google Scholar PubMed BibTeX E…

  5. Visualization of Patient-Generated Health Data: A Scoping Review of Dashboard Designs | CDSiC

    cdsic.ahrq.gov/cdsic/pghd_dashboard_manuscript
    September 13, 2023 - : Skip to main content HHS.gov Menu Main navigation CDS Home CDS Innovation Collaborative An official website of the Department of Health & Human Services …

  6. Using the medication error prioritization system to improve patient safety. | PSNet

    psnet.ahrq.gov/issue/using-medication-error-prioritization-system-improve-patient-safety
    May 01, 2020 - Commentary Using the medication error prioritization system to improve patient safety. Citation Text: Polnariev A. Using the Medication Error Prioritization System To Improve Patient Safety. P T. 2016;41(1):54-9. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3…

  7. The right and wrong way to talk to patients about adverse events. | PSNet

    psnet.ahrq.gov/issue/right-and-wrong-way-talk-patients-about-adverse-events
    November 01, 2023 - Newspaper/Magazine Article The right and wrong way to talk to patients about adverse events. Citation Text: Beaulieu-Volk D. The right and wrong way to talk to patients about adverse events. Medical economics. 2014;91(11):52-5. Copy Citation Format: Google Scholar PubMed Bi…

  8. Tort reform and the patient safety movement: seeking common ground. | PSNet

    psnet.ahrq.gov/issue/tort-reform-and-patient-safety-movement-seeking-common-ground
    August 04, 2021 - Commentary Tort reform and the patient safety movement: seeking common ground. Citation Text: Budetti PP. Tort reform and the patient safety movement: seeking common ground. JAMA. 2005;293(21):2660-2. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote…

  9. New Guide Offers Strategies To Reduce Clinician Burdens | Agency for Healthcare Research and Quality

    www.ahrq.gov/news/blog/ahrqviews/burnout-in-primary-care-guide.html
    April 01, 2023 - AHRQ Views: Blog posts from AHRQ leaders New Guide Offers Strategies To Reduce Clinician Burdens APR 24 2023 By Robert Otto Valdez, Ph.D., M.H.S.A. Robert Otto Valdez, Ph.D., M.H.S.A. In recent years, primary care physicians have struggled with burnout brought on …

  10. Age-related COVID-19 vaccine mix-ups. | PSNet

    psnet.ahrq.gov/issue/age-related-covid-19-vaccine-mix-ups
    June 13, 2018 - Press Release/Announcement Age-related COVID-19 vaccine mix-ups. Citation Text: Age-related COVID-19 vaccine mix-ups. National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. December 6, 2021.  Cop…

  11. Outpatient | Digital Healthcare Research

    digital.ahrq.gov/care-setting/hospital-outpatient
    January 01, 2023 - Outpatient Examining the Feasibility and Effectiveness of an mHealth Solution Designed to Enhance Clinical Outcomes Among Patients Attending Physical Therapy for Musculoskeletal Pain Description This research examines whether remote therapeutic monitoring can improve physical …

  12. Kaiser Permanente School of Anesthesia Uses AHRQ’s Surveys on Patient Safety Culture®, TeamSTEPPS® | Agency for Healthcare Research and Quality

    www.ahrq.gov/news/newsroom/case-studies/202502.html
    June 01, 2025 - Kaiser Permanente School of Anesthesia Uses AHRQ’s Surveys on Patient Safety Culture®, TeamSTEPPS® Search All Impact Case Studies June 2025 Kaiser Permanente (KP) School of Anesthesia in Pasadena, California, uses AHRQ’s  Surveys on Patient Safety Culture (SOPS®) to improve ambulatory care and expand docto…

  13. Medication Safety | Digital Healthcare Research

    digital.ahrq.gov/health-care-theme/medication-safety
    January 01, 2023 - Medication Safety Identifying Sepsis Phenotypes Associated with Antibiotic-Resistant Pathogens Using Large Language Models and Machine Learning Description This research uses large language models and machine learning to retrospectively analyze electronic health records of pa…

  14. Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2022 User Database Report. | PSNet

    psnet.ahrq.gov/issue/surveys-patient-safety-culture-sops-medical-office-survey-2022-user-database-report
    June 01, 2022 - Book/Report Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2022 User Database Report. Citation Text: Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2022 User Database Report. Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare R…

  15. Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency. | PSNet

    psnet.ahrq.gov/issue/liquid-medication-dosing-errors-hispanic-parents-role-health-literacy-and-english-proficiency
    December 14, 2016 - Study Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency. Citation Text: Harris LM, Dreyer BP, Mendelsohn A, et al. Liquid Medication Dosing Errors by Hispanic Parents: Role of Health Literacy and English Proficiency. Acad Pediatr. 2017;1…

  16. Case study: preventing surgical complications at Baystate Medical Center. | PSNet

    psnet.ahrq.gov/issue/case-study-preventing-surgical-complications-baystate-medical-center
    May 27, 2011 - Commentary Case study: preventing surgical complications at Baystate Medical Center. Citation Text: Fitzgerald J, Kanter G, Benjamin EM. Case Study: Preventing Surgical Complications at Baystate Medical Center. The Joint Commission Journal on Quality and Patient Safety. 2016;33(11). doi:…

  17. Acute care patients discuss the patient role in patient safety. | PSNet

    psnet.ahrq.gov/issue/acute-care-patients-discuss-patient-role-patient-safety
    October 12, 2011 - Study Acute care patients discuss the patient role in patient safety. Citation Text: Rathert C, Huddleston N, Pak Y. Acute care patients discuss the patient role in patient safety. Health Care Manage Rev. 2011;36(2):134-144. doi:10.1097/HMR.0b013e318208cd31. Copy Citation Format:…

  18. Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making. | PSNet

    psnet.ahrq.gov/issue/evaluating-physician-performance-individualizing-care-pilot-study-tracking-contextual-errors
    September 20, 2011 - Study Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making. Citation Text: Weiner SJ, Schwartz A, Yudkowsky R, et al. Evaluating physician performance at individualizing care: a pilot study tracking contextual err…

  19. Healthy work environments, nurse-physician communication, and patients' outcomes. | PSNet

    psnet.ahrq.gov/issue/healthy-work-environments-nurse-physician-communication-and-patients-outcomes
    June 05, 2024 - Study Healthy work environments, nurse-physician communication, and patients' outcomes. Citation Text: Manojlovich M, DeCicco B. Healthy work environments, nurse-physician communication, and patients' outcomes. Am J Crit Care. 2007;16(6):536-43. Copy Citation Format: Goog…

  20. Tip 3. Make It Easy to Skim Your Health Care Quality Report | Agency for Healthcare Research and Quality

    www.ahrq.gov/talkingquality/resources/writing/tip3.html
    May 01, 2015 - Tip 3. Make It Easy to Skim Your Health Care Quality Report While some people will read a report from beginning to end, many do not move systematically through the information. By interviewing readers and watching what they do, researchers have found that some people flip through reports in search of useful i…
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