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psnet.ahrq.gov/issue/adverse-health-care-events-reporting-system-what-have-we-learned
February 28, 2015 - Book/Report
Adverse Health Care Events Reporting System: What Have We Learned?
Citation Text:
Adverse Health Care Events Reporting System: What Have We Learned? St. Paul, MN: Minnesota Department of Health; January 2009.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/obsrounds.doc
June 02, 2025 - Observing Patient Care Rounds
Problem statement: Interdisciplinary rounds are in the best interest of patients. Poor communication among staff is a root cause of many patient adverse and sentinel events. Communication among disciplines can be improved if viewed through the eyes of an objective observer.
What are obser…
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psnet.ahrq.gov/issue/cleveland-clinic-health-system-comprehensive-framework-health-system-patient-safety
January 04, 2017 - Commentary
Cleveland Clinic Health System: a comprehensive framework for a health system patient safety initiative.
Citation Text:
Cleveland Clinic Health System: a comprehensive framework for a health system patient safety initiative. Nadzam DM; Atkins PM; Waggoner DM; Shonk R.
Co…
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psnet.ahrq.gov/issue/despite-technology-verbal-orders-persist-read-back-not-widespread-and-errors-continue
June 28, 2017 - Newspaper/Magazine Article
Despite technology, verbal orders persist, read back is not widespread, and errors continue.
Citation Text:
Despite technology, verbal orders persist, read back is not widespread, and errors continue. ISMP Medication Safety Alert! Acute Care Edition. May 18, 20…
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psnet.ahrq.gov/issue/inattentional-blindness-what-captures-your-attention-0
November 24, 2021 - Commentary
'Inattentional blindness': what captures your attention?
Citation Text:
Grissinger M. 'Inattentional blindness': what captures your attention? P.T. 2012;37(10):542-555.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/055-guide-nursing-practice.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
Decolonization Nursing Practice Guide
Use this guide to help ensure that all nursing practice procedures and leadership support are in place to actively support the decolonization intervention.
Engagement & Collaboration
Determine Which Patients Need Treatment
CHG Bath Docume…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/commitment-poster-spanish.docx
September 01, 2022 - Commitment Poster (Spanish)
NOS COMPROMETEMOS A RECETARLE ANTIBIÓTICOS ÚNICAMENTE CUANDO LE VAN A SERVIR
Los antibióticos solamente combaten las infecciones ocasionadas por bacterias.
Tomar antibióticos cuando no los necesita NO lo hará sentirse mejor. Seguirá sintiéndose enfermo y el antibiótico puede causarle salpu…
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psnet.ahrq.gov/issue/tenfold-errors-can-lead-tragedy
February 21, 2007 - Newspaper/Magazine Article
Tenfold errors can lead to tragedy.
Citation Text:
Tenfold errors can lead to tragedy. Sipkoff M. Drug Topics. August 21, 2006.
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psnet.ahrq.gov/issue/eliminating-insulin-errors-rphs-share-tricks
June 13, 2011 - Newspaper/Magazine Article
Eliminating insulin errors: RPhs share tricks.
Citation Text:
Eliminating insulin errors: RPhs share tricks. Cassell D. Drug Topics. March 20, 2006.
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psnet.ahrq.gov/issue/medication-errors
August 21, 2018 - Commentary
Medication errors.
Citation Text:
Medication errors. Hartigan-Go K. Int J Risk Safety Med. 2006;18(3):181-186.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/monitoring-programs-rapid-research.pdf
April 01, 2025 - primary care and other ambulatory care settings
(e.g., specialty practices, urgent care facilities),
pharmacies … Implementing
green supply chain management for online
pharmacies through a VADD inventory model. … An
audit of drug shortages in a community
pharmacy practice. … group purchasing structure
in the field of pharmaceuticals and medical
devices: The case of public pharmacies
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015196-crandall-final-report-2007.pdf
January 01, 2007 - PowerNote documentation usage by residents and
faculty, the percent of prescriptions entered and faxed to pharmacies … All prescriptions were entered and faxed
to pharmacies.
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS
August 1, 2009
Also Read an Essay
Citation Text:
In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.In Conversation with...Steven J. Spear, DBA, MS, MS . PSNet [internet]. Rockville (MD…
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www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-6.html
July 01, 2019 - Case Example #6: Henry Ford Health System
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…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Furmaga.pdf
January 01, 2005 - Reducing the Use of Short-acting Nifedipine by Hypertensives Using a Pharmaceutical Database
277
Reducing the Use of Short-acting
Nifedipine by Hypertensives Using
a Pharmaceutical Database
Elaine M. Furmaga, Peter A. Glassman,
Francesca E. Cunningham, Chester B. Good
Abstract
Objective: In view of the wi…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/apcd/apcd-inventory.xlsx
October 01, 2015 - Sheet1
Measure Characteristics Overall Measure Inventory Details Deep Dive Measure Inventory Details
Condition of Focus Measure Condition Subcategory Measure Type (Cost, Quality, or Utilization) Quality Category (Process, Outcomes, Structure, Not Applicable) Measure Name or Paper Name (From Lit Review) …
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effectivehealthcare.ahrq.gov/sites/default/files/upenn-final-report-2005-certs-ce-supplement.pdf
January 01, 2005 - Michigan and Minnesota to its primary sources, i.e., clinical records hospitals, physician
offices, pharmacies
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/administrative-data-validity_research.pdf
January 01, 2007 - Michigan and Minnesota to its primary sources, i.e., clinical records hospitals, physician
offices, pharmacies
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effectivehealthcare.ahrq.gov/sites/default/files/cer-239-acute-migraine-evidence-summary.pdf
December 01, 2020 - applicability, several of the established drugs, such as the ergot
alkaloids, may not be reliably stocked by pharmacies
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www.ahrq.gov/sites/default/files/wysiwyg/lhs/lhs_case_studies_utah_health.pdf
April 01, 2019 - patient, including: scheduling; checking in at a clinic or hospital; visiting clinicians, labs, and
pharmacies