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www.ahrq.gov/news/newsroom/case-studies/202301.html
October 01, 2024 - Ohio Veterans’ Facility Relied on AHRQ Resource to Develop Diabetes Initiative
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March 2023
The Dayton (Ohio) Veterans Affairs (VA) Medical Center facility has adopted AHRQ’s SHARE Approach as part of the U.S. Department of Veterans Affairs' national Hypoglycemic Safety Initia…
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psnet.ahrq.gov/issue/limited-health-literacy-barrier-medication-reconciliation-ambulatory-care
March 24, 2010 - Study
Limited health literacy is a barrier to medication reconciliation in ambulatory care.
Citation Text:
Persell SD, Osborn CY, Richard R, et al. Limited health literacy is a barrier to medication reconciliation in ambulatory care. J Gen Intern Med. 2007;22(11):1523-6.
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psnet.ahrq.gov/issue/medication-errors-resulting-computer-entry-nonprescribers
January 02, 2017 - Study
Medication errors resulting from computer entry by nonprescribers.
Citation Text:
Santell JP, Kowiatek JG, Weber RJ, et al. Medication errors resulting from computer entry by nonprescribers. Am J Health Syst Pharm. 2009;66(9):843-53. doi:10.2146/ajhp080208.
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psnet.ahrq.gov/issue/drug-administration-errors-institution-individuals-intellectual-disability-observational
October 18, 2023 - Study
Drug administration errors in an institution for individuals with intellectual disability: an observational study.
Citation Text:
van den Bemt PMLA, Robertz R, de Jong AL, et al. Drug administration errors in an institution for individuals with intellectual disability: an observa…
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psnet.ahrq.gov/issue/patient-safety-primary-care-has-many-aspects-interview-study-primary-care-doctors-and-nurses
July 23, 2008 - Study
Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses.
Citation Text:
Gaal S, van Laarhoven E, Wolters R, et al. Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses. J Eval Clin Pr…
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psnet.ahrq.gov/issue/hospital-ward-incidents-through-eyes-nurses-thick-description-appeal-and-deadlock-incident
November 15, 2023 - Study
Hospital ward incidents through the eyes of nurses – a thick description on the appeal and deadlock of incident reporting systems.
Citation Text:
Tresfon J, van Winsen R, Brunsveld-Reinders AH, et al. Hospital ward incidents through the eyes of nurses - a thick description on the a…
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psnet.ahrq.gov/issue/preventing-medication-errors-quality-chasm-series
January 04, 2009 - Book/Report
Classic
Preventing Medication Errors: Quality Chasm Series.
Citation Text:
Preventing Medication Errors: Quality Chasm Series. Aspden P, Wolcott J, Bootman JL, et al, eds; Institute of Medicine, Committee on Identifying and Preventing Medication …
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psnet.ahrq.gov/issue/medication-administration-aged-care-facilities-mixed-methods-systematic-review-0
July 31, 2024 - Review
Medication administration in aged care facilities: a mixed-methods systematic review.
Citation Text:
Garratt S, Dowling A, Manias E. Medication administration in aged care facilities: a mixed‐methods systematic review. J Adv Nurs. 2025;81(2):621-640. doi:10.1111/jan.16318.
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psnet.ahrq.gov/issue/artificial-intelligence-health-care-accountability-and-safety
December 20, 2023 - Commentary
Classic
Artificial intelligence in health care: accountability and safety.
Citation Text:
Habli I, Lawton T, Porter Z. Artificial intelligence in health care: accountability and safety. Bull World Health Organ. 2020;98(4):251-256. doi:10.2471/blt.19.2…
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psnet.ahrq.gov/issue/instruments-patient-safety-assessment-scoping-review
October 12, 2022 - Review
Instruments for patient safety assessment: a scoping review.
Citation Text:
Nunes E, Sirtoli F, Lima E, et al. Instruments for patient safety assessment: a scoping review. Healthcare. 2024;12(20):2075. doi:10.3390/healthcare12202075.
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psnet.ahrq.gov/issue/machine-learning-medication-prescription-systematic-review
October 16, 2013 - Study
Machine learning in medication prescription: a systematic review.
Citation Text:
Iancu A, Leb I, Prokosch H-U, et al. Machine learning in medication prescription: a systematic review. Int J Med Inform. 2023;180:105241. doi:10.1016/j.ijmedinf.2023.105241.
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psnet.ahrq.gov/issue/value-assessment-deprescribing-interventions-suggestions-improvement
August 04, 2021 - Commentary
Value assessment of deprescribing interventions: suggestions for improvement.
Citation Text:
Hung A, Wang J, Moriarty F, et al. Value assessment of deprescribing interventions: suggestions for improvement. J Am Geriatr Soc. 2023;71(6):2023-2027. doi:10.1111/jgs.18298.
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psnet.ahrq.gov/issue/evaluation-and-accurate-diagnoses-pediatric-diseases-using-artificial-intelligence
April 15, 2020 - Study
Classic
Evaluation and accurate diagnoses of pediatric diseases using artificial intelligence.
Citation Text:
Liang H, Tsui BY, Ni H, et al. Evaluation and accurate diagnoses of pediatric diseases using artificial intelligence. Nat Med. 2019;25(3):433-438.…
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psnet.ahrq.gov/issue/five-strategies-safer-ehr-modernization-journey
November 11, 2020 - Commentary
Five strategies for a safer EHR modernization journey.
Citation Text:
Sittig DF, Yackel EE, Singh H. Five strategies for a safer EHR modernization journey. J Gen Intern Med. 2023;38(S4):940-942. doi:10.1007/s11606-023-08331-z.
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psnet.ahrq.gov/issue/development-icu-safety-reporting-system
May 27, 2011 - Study
Development of the ICU safety reporting system.
Citation Text:
Development of the ICU safety reporting system. Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1(1):23-32.
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psnet.ahrq.gov/issue/what-happened-my-patient-educational-intervention-facilitate-postdischarge-patient-follow
June 22, 2022 - Commentary
What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up.
Citation Text:
Narayana S, Rajkomar A, Harrison JD, et al. What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up. J Grad Med…
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psnet.ahrq.gov/issue/using-electronic-health-records-identify-adverse-drug-events-ambulatory-care-systematic
May 04, 2012 - Review
Using electronic health records to identify adverse drug events in ambulatory care: a systematic review.
Citation Text:
Feng C, Le D, McCoy AB. Using Electronic Health Records to Identify Adverse Drug Events in Ambulatory Care: A Systematic Review. Appl Clin Inform. 2019;10(1):123…
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psnet.ahrq.gov/issue/chemotherapy-medication-errors-pediatric-cancer-treatment-center-prospective-characterization
January 22, 2017 - Study
Chemotherapy medication errors in a pediatric cancer treatment center: prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate.
Citation Text:
Watts RG, Parsons K. Chemotherapy medication errors in a pe…
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psnet.ahrq.gov/issue/impact-pharmacist-provided-medication-therapy-management-healthcare-quality-and-utilization
November 16, 2022 - Study
Impact of pharmacist-provided medication therapy management on healthcare quality and utilization in recently discharged elderly patients.
Citation Text:
Haag JD, Davis AZ, Hoel RW, et al. Impact of Pharmacist-Provided Medication Therapy Management on Healthcare Quality and Utiliza…
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psnet.ahrq.gov/issue/bad-behavior-healthcare-insidious-threat-patients-staff-and-organizations
October 16, 2019 - Commentary
Bad behavior in healthcare: an insidious threat to patients, staff, and organizations.
Citation Text:
Crowe L, Riley CM. Bad behavior in healthcare: an insidious threat to patients, staff, and organizations. Curr Opin Cardiol. 2024;39(4):331-337. doi:10.1097/hco.00000000000011…