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psnet.ahrq.gov/issue/role-remediation-cases-serious-misconduct-uk-healthcare-regulators-qualitative-study
June 02, 2021 - Study
Role of remediation in cases of serious misconduct before UK healthcare regulators: a qualitative study.
Citation Text:
Price T, Reynolds E, O’Brien T, et al. Role of remediation in cases of serious misconduct before UK healthcare regulators: a qualitative study. BMJ Qual Saf. 2025…
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psnet.ahrq.gov/issue/computer-physician-order-entry-benefits-costs-and-issues
May 27, 2011 - Study
Computer physician order entry: benefits, costs, and issues.
Citation Text:
Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med. 2003;139(1):31-9.
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psnet.ahrq.gov/issue/quality-improvement-through-implementation-discharge-order-reconciliation
September 23, 2020 - Commentary
Quality improvement through implementation of discharge order reconciliation.
Citation Text:
Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050. …
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psnet.ahrq.gov/issue/how-should-medication-errors-be-defined-development-and-test-definition
June 27, 2011 - Study
How should medication errors be defined? Development and test of a definition.
Citation Text:
Lisby M, Nielsen LP, Brock B, et al. How should medication errors be defined? Development and test of a definition. Scand J Public Health. 2012;40(2):203-10. doi:10.1177/1403494811435489.…
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psnet.ahrq.gov/issue/time-out-impact-physician-burnout-patient-care-quality-and-safety-perioperative-medicine
November 03, 2021 - Commentary
Time out: the impact of physician burnout on patient care quality and safety in perioperative medicine.
Citation Text:
Shin P, Desai V, Conte AH, et al. Time out: the impact of physician burnout on patient care quality and safety in perioperative medicine. Perm J. 2023;27(2):1…
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psnet.ahrq.gov/issue/why-it-so-hard-talk-about-overuse-pediatrics-and-why-it-matters
March 04, 2020 - Commentary
Why it is so hard to talk about overuse in pediatrics and why it matters.
Citation Text:
Ralston SL, Schroeder AR. Why It Is So Hard to Talk About Overuse in Pediatrics and Why It Matters. JAMA Pediatr. 2017;171(10):931-932. doi:10.1001/jamapediatrics.2017.2239.
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psnet.ahrq.gov/issue/nonhospital-health-care-associated-hepatitis-b-and-c-virus-transmission-united-states-1998
October 19, 2012 - Review
Nonhospital health care–associated hepatitis B and C virus transmission: United States, 1998-2008.
Citation Text:
Thompson ND, Perz JF, Moorman AC, et al. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med. 2009;150(1)…
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psnet.ahrq.gov/issue/effect-computerized-physician-order-entry-radiologic-examination-order-indication-quality
June 13, 2015 - Study
Effect of computerized physician order entry on radiologic examination order indication quality.
Citation Text:
Schneider E, Franz W, Spitznagel R, et al. Effect of computerized physician order entry on radiologic examination order indication quality. Arch Intern Med. 2011;171(11…
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psnet.ahrq.gov/issue/systematic-review-performance-characteristics-clinical-event-monitor-signals-used-detect
March 28, 2012 - Review
A systematic review of the performance characteristics of clinical event monitor signals used to detect adverse drug events in the hospital setting.
Citation Text:
Handler S, Altman RL, Perera S, et al. A systematic review of the performance characteristics of clinical event mon…
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psnet.ahrq.gov/issue/see-one-sim-one-do-one-national-pre-internship-boot-camp-ensure-safer-student-doctor
February 16, 2011 - Study
"See One, Sim One, Do One"—a national pre-internship boot-camp to ensure a safer "student to doctor" transition.
Citation Text:
Minha S'ar, Shefet D, Sagi D, et al. "See One, Sim One, Do One"- A National Pre-Internship Boot-Camp to Ensure a Safer "Student to Doctor" Transition. PLo…
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psnet.ahrq.gov/issue/reconcilable-differences-correcting-medication-errors-hospital-admission-and-discharge
February 13, 2019 - Study
Reconcilable differences: correcting medication errors at hospital admission and discharge.
Citation Text:
Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006;15(2):122-6.
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psnet.ahrq.gov/issue/look-alike-sound-alike-drugs-review-include-look-alike-packaging-additional-safety-check
March 24, 2021 - Study
Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check.
Citation Text:
McCoy LK. Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check. Jt Comm J Qual Patient Saf. 2005;31(1):47-53.
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psnet.ahrq.gov/issue/rapid-response-systems-identification-and-management-prearrest-state
May 18, 2022 - Review
Rapid response systems: identification and management of the "prearrest state."
Citation Text:
McCurdy MT, Wood SL. Rapid response systems: identification and management of the "prearrest state". Emerg Med Clin North Am. 2012;30(1):141-52. doi:10.1016/j.emc.2011.09.012.
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digital.ahrq.gov/sites/default/files/docs/citation/EHRVendorPracticesPerspectives.pdf
May 01, 2010 - PowerWorks ePrescribe partners with
SuperScripts®, a third-party provider with access to 95 percent of the pharmacies … Centricity EMR’s e-Prescribing function can connect to over 95 percent of the country’s
pharmacies
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/gap_analysis_tool.docx
November 01, 2019 - Gap Analysis for Antibiotic Stewardship Programs
AHRQ Safety Program for Improving Antibiotic Use
Gap Analysis for Antibiotic Stewardship Programs
Instructions: Complete this document to assess your antibiotic stewardship program (ASP) on an annual basis. The ASP areas addressed in this document are those that are d…
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - Personal Health Literacy
August 30, 2023
Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/personal-health-literacy
Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in
August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - SPOTLIGHT CASE
When the Indications for Drug Administration Blur
Citation Text:
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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digital.ahrq.gov/sites/default/files/docs/survey/mainehealthcoalitionossurvey_comp.pdf
January 01, 2007 - Maine Health Management Coalition: Office Systems Survey
Maine Health Management Coalition
Pathways to Excellence - Office Systems Survey 2007
Please fill out only one form for each practice location.
Instructions
You may use the tab key to na…
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance
Measurement Tracking, and Performance Feedback
February 28, 2024
https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-
and-performance
Summary
To improve patient care and outcomes in the intensive care unit (ICU…