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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - Staggered Sensitivity Results
Citation Text:
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Lavelle_33.pdf
March 12, 2008 - interest in adapting the curriculum for the staff of the HealthPartners
dental clinics and the outpatient pharmacies
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous
Combination
April 24, 2024
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous
Combination. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
The Case
A 26-ye…
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/node/60745/psn-pdf
October 01, 2020 - Multiple High-Risk Events Involving Workflow for Wasting
of Medications Used by Anesthesia
July 29, 2020
Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications
Used by Anesthesia. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-high-risk-events-involvi…
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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digital.ahrq.gov/sites/default/files/ahrq-dhr-schedule-amia-2024.pdf
January 01, 2024 - Ballroom
Session Code: P92
Feasibility Pilot of Linking Patient-Reported Outcomes Collected
in Community … Pharmacies with Electronic Health Record Data
5:00 PM – 6:30 PM PST
Poster
Grand Ballroom
Session
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/2-unc-webcast-ginsberg.pdf
June 02, 2025 - organizational culture supports patient safety
Hospital
(2004)
Nursing
Home
(2008)
Medical
Office
(2009)
Community … Pharmacy
(2012)
Ambulatory
Surgery
Center
(2015)
Uses for SOPS surveys
• Raise staff awareness
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digital.ahrq.gov/ahrq-funded-projects/improving-lab-follow-delivering-enhanced-medication-list-outpatient-physician/annual-summary/2010
January 01, 2010 - Improving Lab Followup by Delivering an Enhanced Medication List to Outpatient Physician Practices - 2010
Project Name
Improving Lab Follow-up by Delivering an Enhanced Medication List to Outpatient Physician Practices
Principal Investigator
Simonaitis, Linas
Organization
Ind…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Chan.pdf
July 01, 2004 - Some HMO-owned pharmacies assigned HMO-specific codes to
represent repackaged products, and we identified
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www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-2.html
July 01, 2019 - Case Example #2: The Health Center
This report is based on research conducted by Abt Associates in partnership with the MacColl Center for Health Care Innovation and Bailit Health Purchasing, Cambridge, MA, under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contr…
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psnet.ahrq.gov/issue/safeguarding-storage-drug-products
December 15, 2010 - Newspaper/Magazine Article
Safeguarding the storage of drug products.
Citation Text:
Safeguarding the storage of drug products. PA-PSRS Patient Saf Advis. 2010;7(2):46-51.
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Fac…
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psnet.ahrq.gov/issue/health-literacy
December 23, 2011 - Special or Theme Issue
Health Literacy.
Citation Text:
Health Literacy. J Gen Intern Med. 2006;21(8):806-899.
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…
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psnet.ahrq.gov/issue/drug-shortages-obama-tries-prevent-emergencies
April 10, 2024 - Newspaper/Magazine Article
Drug shortages: Obama tries to prevent emergencies.
Citation Text:
Drug shortages: Obama tries to prevent emergencies. Neergaard L. San Francisco Chronicle; November 1, 2011:A6.
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Dow…
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www.ahrq.gov/research/findings/final-reports/ptmgmt/ptmgmttab4.html
July 01, 2018 - Patient Self-Management Support Programs: An Evaluation
Table 4. AADE Recommended Measures and Measurement Methods
Previous Page
Table of Contents
Patient Self-Management Support Programs: An Evaluation
Acknowledgments
Introduction and Purpose
Summary
Background
Methodology
Design Opti…
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psnet.ahrq.gov/issue/medication-assessment-one-determinant-falls-risk
July 24, 2013 - Newspaper/Magazine Article
Medication assessment: one determinant of falls risk.
Citation Text:
Medication assessment: one determinant of falls risk. PA-PSRS Patient Saf Advis. March 2008;5:16-18.
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psnet.ahrq.gov/issue/medication-reconciliation-getting-started-it
April 27, 2016 - Newspaper/Magazine Article
Medication reconciliation: getting started with IT.
Citation Text:
Medication reconciliation: getting started with IT. Lefeber J
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apa.html
August 01, 2022 - Event Investigation and Analysis Guide: Appendix A
Five Whys
In this example, there is only one path shown, but answers can create multiple paths and more questions.
Event Summary: The wrong concentration of potassium (K+) was used in the compounding of TPN. This was discovered almost 2 months later.
1s…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-28
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR. ISMP medication error report analysis. Hosp Pharm. 2010;43(8):618-620. doi:10.1310/hpj4308-618.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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digital.ahrq.gov/program-overview/research-stories/breathing-easy-virtual-medication-education-patients-chronic-obstructive-pulmonary-disease
January 01, 2023 - Breathing Easy: Virtual Medication Education for Patients with Chronic Obstructive Pulmonary Disease
Theme:
Engaging and Empowering Patients and Caregivers
Subtheme:
Improving Care During Patient Transitions
Virtual visits with members of a pharmacy team can support patients recently disch…