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psnet.ahrq.gov/node/39680/psn-pdf
July 14, 2010 - Safety of using a computerized rounding and sign-out
system to reduce resident duty hours.
July 14, 2010
Van Eaton EG, McDonough K, Lober WB, et al. Safety of Using a Computerized Rounding and Sign-Out
System to Reduce Resident Duty Hours. Academic Medicine. 2010;85(7).
doi:10.1097/acm.0b013e3181e0116f.
https://p…
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psnet.ahrq.gov/node/60310/psn-pdf
May 06, 2020 - ‘They are terrified’: fearing coronavirus, people with
potentially fatal conditions avoid emergency care.
May 6, 2020
Bruggeman L, Bhatt J. ABC News. April 23, 2020.
https://psnet.ahrq.gov/issue/they-are-terrified-fearing-coronavirus-people-potentially-fatal-conditions-avoid-
emergency
Patient ability to acc…
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psnet.ahrq.gov/node/46963/psn-pdf
April 18, 2018 - A Just Culture Guide.
April 18, 2018
NHS Improvement. London, UK: National Health Service; March 15, 2018.
https://psnet.ahrq.gov/issue/just-culture-guide
Although focusing on system failure has been highlighted as key to improving patient safety, individual
behaviors must also be recognized as contributors to ris…
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psnet.ahrq.gov/node/46461/psn-pdf
November 01, 2017 - Complications: acknowledging, managing, and coping
with human error.
November 1, 2017
Helo S, Moulton C-AE. Complications: acknowledging, managing, and coping with human error. Transl
Androl Urol. 2017;6(4):773-782. doi:10.21037/tau.2017.06.28.
https://psnet.ahrq.gov/issue/complications-acknowledging-managing-and-…
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psnet.ahrq.gov/node/40085/psn-pdf
December 15, 2010 - Medication reconciliation in the emergency department:
opportunities for workflow redesign.
December 15, 2010
Hummel J, Evans PC, Lee H. Medication reconciliation in the emergency department: opportunities for
workflow redesign. Qual Saf Health Care. 2010;19(6):531-5. doi:10.1136/qshc.2009.035121.
https://psnet.ah…
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www.ahrq.gov/action-alliance/webinars/safer-guides.html
February 01, 2025 - National Action Alliance Webinar: Engineering Safety Into Practice Through Implementation of the 2025 SAFER Guides
Summary On January 21, 2025, Dean Sittig, Ph.D., and Hardeep Singh, M.D., M.P.H., the authors of the Safety Assurance Factors for EHR Resilience (SAFER) Guides, discussed the development of the lat…
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psnet.ahrq.gov/node/60766/psn-pdf
August 05, 2020 - Dermatology faces a reckoning: lack of darker skin in
textbooks and journals harms care for patients of color.
August 5, 2020
McFarling UL. Stat. July 21, 2020.
https://psnet.ahrq.gov/issue/dermatology-faces-reckoning-lack-darker-skin-textbooks-and-journals-harms-
care-patients-color
Dermatologists rely on v…
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psnet.ahrq.gov/node/45581/psn-pdf
October 19, 2016 - Reducing diagnostic errors.
October 19, 2016
Gittlen S. HealthLeaders Media. October 1, 2016.
https://psnet.ahrq.gov/issue/reducing-diagnostic-errors-0
The recent recognition of diagnostic error as a blind spot in health care has driven the need to enhance
diagnosis. This news article reports how health systems, a…
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psnet.ahrq.gov/node/38261/psn-pdf
December 03, 2008 - Systematic assessment of culture review as a tool to
assess errors in the clinical microbiology laboratory.
December 3, 2008
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 Pathol Lab Med. 2008;132(11):1792-5…
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psnet.ahrq.gov/node/44041/psn-pdf
April 01, 2015 - Potentially dangerous confusion between Bloxiverz
(neostigmine) injection and Vazculep (phenylephrine)
injection.
April 1, 2015
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American
Society of Health-System Pharmacists. March 23, 2015
https://psnet.ahrq.gov/issue/pot…
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psnet.ahrq.gov/node/50867/psn-pdf
February 05, 2020 - Cognitive testing of older clinicians prior to
recredentialing.
February 5, 2020
Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA.
2020;323(2):179-180. doi:10.1001/jama.2019.18665.
https://psnet.ahrq.gov/issue/cognitive-testing-older-clinicians-prior-recredentialing
In an…
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psnet.ahrq.gov/node/60567/psn-pdf
June 03, 2020 - Keeping Nursing Home Residents and Staff Safe in the
Era of COVID-19.
June 3, 2020
National Academy of Medicine. April-June 2020.
https://psnet.ahrq.gov/issue/keeping-nursing-home-residents-and-staff-safe-era-covid-19
Nursing homes are care environments that are particularly challenged by the COVID-19 pandemic. Th…
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psnet.ahrq.gov/node/38416/psn-pdf
February 18, 2009 - Preanalytical errors in primary healthcare: a
questionnaire study of information search procedures,
test request management and test tube labelling.
February 18, 2009
Söderberg J, Brulin C, Grankvist K, et al. Preanalytical errors in primary healthcare: a questionnaire study
of information search procedures, test …
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psnet.ahrq.gov/node/45647/psn-pdf
February 22, 2017 - Bias in the ER. Doctors suffer from the same cognitive
distortions as the rest of us.
February 22, 2017
Lewis M. Nautilus. February 9, 2017.
https://psnet.ahrq.gov/issue/bias-er-doctors-suffer-same-cognitive-distortions-rest-us
Physicians' decision-making can be diminished when they are tired, distracted, or too n…
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psnet.ahrq.gov/node/43464/psn-pdf
August 27, 2014 - Using pharmacists to optimize patient outcomes and
costs in the ED.
August 27, 2014
Jacknin G, Nakamura T, Smally AJ, et al. Using pharmacists to optimize patient outcomes and costs in the
ED. Am J Emerg Med. 2014;32(6):673-7. doi:10.1016/j.ajem.2013.11.031.
https://psnet.ahrq.gov/issue/using-pharmacists-optimize-…
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www.ahrq.gov/evidencenow/heart-health/smoking/treatment.html
August 01, 2018 - Treating Tobacco Use and Dependence: 2008 Update by HHS Panel
Resource title: Treating Tobacco Use and Dependence: 2008 Update
Resource description: This update to a previous guideline by the Tobacco Use and Dependence Guideline Panel contains strategies and recommendations for effective treatments for tob…
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effectivehealthcare.ahrq.gov/sites/default/files/delilberative-methods-design-goold-2.pdf
May 29, 2025 - Educating Session Participants
Slide 19
Educating Session Participants
Susan Dorr Goold, MD, MHSA, MA
Professor of Internal Medicine and
Health Management and Policy
University of Michigan
Slide 20
Educating Session Participants
Deliberative procedures usually inform, educate participants
Materia…
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www.ahrq.gov/priority-populations/publications/richardson-et-al-2020.html
January 01, 2021 - Health and Economic Outcomes of Newborn Screening for Infantile-onset Pompe Disease
Pompe disease is a rare condition that is identified in about 1 in 40,000 births. It occurs from a defect in the GAA gene leading to the accumulation of lysosomal glycogen and, depending on the form and severity, can result in c…
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digital.ahrq.gov/ahrq-funded-projects/using-health-information-technology-improve-health-care-quality-primary-care-va/publication/handbook
January 01, 2023 - An interactive preventive care record: a handbook for using patient-centered personal health records to promote prevention.
Citation
Krist A, Rothemich S, Kashiri P, et al. An interactive preventive care record: a handbook for using patient-centered personal health records to promote prevention. (Prep…
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digital.ahrq.gov/ahrq-funded-projects/decision-making-and-clinical-work-test-result-followup-health-information/final-report
January 01, 2023 - Decision Making and Clinical Work of Test Result Followup in Health Information Technology Settings - Final Report
Citation
Singh H. Decision Making and Clinical Work of Test Result Followup in Health Information Technology Settings - Final Report. (Prepared by Baylor College of Medicine under Grant N…