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psnet.ahrq.gov/issue/implementation-mock-root-cause-analysis-provide-simulated-patient-safety-training
January 12, 2022 - Commentary
Implementation of a mock root cause analysis to provide simulated patient safety training.
Citation Text:
Murphy M, Duff J, Whitney J, et al. Implementation of a mock root cause analysis to provide simulated patient safety training. BMJ Open Qual. 2017;6(2). doi:10.1136/bmjoq-…
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psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-safe-administration-chemotherapy-hospitalized
August 08, 2018 - Study
Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer.
Citation Text:
Robinson DL, Heigham M, Clark J. Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer…
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psnet.ahrq.gov/issue/patterns-dementia-treatment-and-frank-prescribing-errors-older-adults-parkinson-disease
September 18, 2024 - Study
Patterns of dementia treatment and frank prescribing errors in older adults with Parkinson disease.
Citation Text:
Mantri S, Fullard M, Gray SL, et al. Patterns of Dementia Treatment and Frank Prescribing Errors in Older Adults With Parkinson Disease. JAMA Neurol. 2019;76(1):41-49.…
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psnet.ahrq.gov/issue/direct-oral-anticoagulants-review-common-medication-errors
January 12, 2022 - Review
Emerging Classic
Direct oral anticoagulants: a review of common medication errors.
Citation Text:
Barr D, Epps QJ. Direct oral anticoagulants: a review of common medication errors. J Thromb Thrombolysis. 2019;47(1):146-154. doi:10.1007/s11239-018-1752-9. …
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psnet.ahrq.gov/issue/so-why-didnt-you-think-baby-was-ill-decision-making-acute-paediatrics
April 10, 2019 - Review
'So why didn't you think this baby was ill?' Decision-making in acute paediatrics.
Citation Text:
Roland D, Snelson E. 'So why didn't you think this baby was ill?' Decision-making in acute paediatrics. Arch Dis Child Educ Pract Ed. 2019;104(1):43-48. doi:10.1136/archdischild-2017-…
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psnet.ahrq.gov/issue/effect-implementation-barcode-technology-and-electronic-medication-administration-record
February 24, 2011 - Study
Effect of the implementation of barcode technology and an electronic medication administration record on adverse drug events.
Citation Text:
Truitt E, Thompson R, Blazey-Martin D, et al. Effect of the Implementation of Barcode Technology and an Electronic Medication Administration …
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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
Search All Impact Case Studies
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/nurse-leader-attitudes-and-beliefs-regarding-medical-errors
March 12, 2025 - Study
Nurse leader attitudes and beliefs regarding medical errors.
Citation Text:
Prothero MM, Huefner K, Sorhus M. Nurse leader attitudes and beliefs regarding medical errors. J Nurs Adm. 2024;54(1):10-15. doi:10.1097/nna.0000000000001371.
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psnet.ahrq.gov/issue/association-polypharmacy-and-potential-drug-drug-interactions-adverse-treatment-outcomes
May 25, 2016 - Study
Association of polypharmacy and potential drug-drug interactions with adverse treatment outcomes in older adults with advanced cancer.
Citation Text:
Mohamed MR, Mohile SG, Juba KM, et al. Association of polypharmacy and potential drug‐drug interactions with adverse treatment outco…
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psnet.ahrq.gov/issue/creating-infrastructure-safety-event-reporting-and-analysis-multicenter-pediatric-emergency
October 08, 2013 - Study
Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network.
Citation Text:
Chamberlain JM, Shaw KN, Lillis KA, et al. Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emer…
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psnet.ahrq.gov/issue/evaluation-occult-fractures-injured-children
August 20, 2014 - Study
Evaluation for occult fractures in injured children.
Citation Text:
Wood JN, French B, Song L, et al. Evaluation for Occult Fractures in Injured Children. Pediatrics. 2015;136(2):232-40. doi:10.1542/peds.2014-3977.
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psnet.ahrq.gov/issue/paradoxical-effects-hospital-based-multi-intervention-programme-aimed-reducing-medication
September 13, 2023 - Study
Paradoxical effects of a hospital-based, multi-intervention programme aimed at reducing medication round interruptions.
Citation Text:
Tomietto M, Sartor A, Mazzocoli E, et al. Paradoxical effects of a hospital-based, multi-intervention programme aimed at reducing medication round …
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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/sociotechnical-work-system-approach-occupational-fatigue
January 15, 2025 - Commentary
Sociotechnical work system approach to occupational fatigue.
Citation Text:
Watterson TL, Steege LM, Mott DA, et al. Sociotechnical work system approach to occupational fatigue. Jt Comm J Qual Patient Saf. 2023;49(9):485-493. doi:10.1016/j.jcjq.2023.05.007.
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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/evaluation-design-and-structure-electronic-medication-labels-improve-patient-health-knowledge
October 16, 2024 - Review
Evaluation of the design and structure of electronic medication labels to improve patient health knowledge and safety: a systematic review.
Citation Text:
Saif S, Bui TTT, Srivastava G, et al. Evaluation of the design and structure of electronic medication labels to improve patien…
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psnet.ahrq.gov/issue/sustaining-quality-improvement-and-patient-safety-training-graduate-medical-education-lessons
July 02, 2014 - Study
Sustaining quality improvement and patient safety training in graduate medical education: lessons from social theory.
Citation Text:
Wong BM, Kuper A, Hollenberg E, et al. Sustaining quality improvement and patient safety training in graduate medical education: lessons from social …
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digital.ahrq.gov/track-9-emerging-approaches-drive-change-healthcare
January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…
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psnet.ahrq.gov/issue/understanding-causes-intravenous-medication-administration-errors-hospitals-qualitative
June 25, 2014 - Study
Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study.
Citation Text:
Keers RN, Williams SD, Cooke J, et al. Understanding the causes of intravenous medication administration errors in hospitals: a qualitative c…
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psnet.ahrq.gov/issue/interprofessional-education-team-communication-working-together-improve-patient-safety
April 24, 2018 - Study
Interprofessional education in team communication: working together to improve patient safety.
Citation Text:
Brock DM, Abu-Rish E, Chiu C-R, et al. Interprofessional education in team communication: working together to improve patient safety. BMJ Qual Saf. 2013;22(5):414-23. doi…