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  1. psnet.ahrq.gov/issue/framework-health-care-organizations-develop-and-evaluate-safety-scorecard
    September 17, 2010 - Commentary A framework for health care organizations to develop and evaluate a safety scorecard. Citation Text: Pronovost P, Berenholtz SM, Needham DM. A framework for health care organizations to develop and evaluate a safety scorecard. JAMA. 2007;298(17):2063-5. Copy Citation F…
  2. 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…
  3. www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/study.html
    May 01, 2017 - Appendix K. Quality Improvement Study Framework - Implementation Guide Study Elements Element Definition Things To Keep in Mind The Purpose Define the problem and why it is important. Avoid suggesting causes in the purpose statement. Cause determination will come later afte…
  4. www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/resources/qapi-leadership-rounding-guide-centers-for-medicare.pdf
    June 02, 2025 - QAPI Leadership Rounding Guide Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance. Directions: Leadership rounding is a process where leaders (e.g., administrator, department heads, and nurse managers) are out in the building with staff and residents, t…
  5. psnet.ahrq.gov/issue/preventable-harm-canadian-organ-donation-and-transplantation-system-descriptive-study-missed
    October 19, 2022 - Study Preventable harm in the Canadian organ donation and transplantation system: a descriptive study of missed organ donor identification and referral. Citation Text: Zavalkoff S, O’Donnell S, Lalani J, et al. Preventable harm in the Canadian organ donation and transplantation system: a…
  6. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20141022_cg/3_julie_susi.pdf
    April 01, 2014 - Achieving Excellence Across All CG-CAHPS Core Measures: Lessons from Top-Performing Medical Practices Mercy Hospital Fore River Campus Portland, Maine 23 Breast Care Specialists of Maine A two-surgeon practice, we take pride in offering timely, accurate consultation and treatment for benign and malignant …
  7. psnet.ahrq.gov/issue/review-best-practices-intravenous-push-medication-administration
    February 21, 2018 - Review A review of best practices for intravenous push medication administration. Citation Text: Lenz JR, Degnan DD, Hertig JB, et al. A Review of Best Practices for Intravenous Push Medication Administration. J Infus Nurs. 2017;40(6):354-358. doi:10.1097/NAN.0000000000000247. Copy Cit…
  8. psnet.ahrq.gov/issue/proposed-2022-cdc-clinical-practice-guideline-prescribing-opioids-notice-centers-disease
    December 21, 2022 - Press Release/Announcement Proposed 2022 CDC clinical practice guideline for prescribing opioids. A notice by the Centers for Disease Control and Prevention. Citation Text: Proposed 2022 CDC clinical practice guideline for prescribing opioids. A notice by the Centers for Disease Control …
  9. www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
    June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use Learning From Antibiotic-Associated Adverse Events An antibiotic-associated adverse event is any event or situation that you would not want to happen again because it either caused your patient harm or had the potential to cause harm. The purpose of this tool is to provi…
  10. psnet.ahrq.gov/issue/benefits-and-burdens-working-patient-safety-organizations-under-patient-safety-and-quality
    October 14, 2020 - Commentary The benefits and burdens of working with patient safety organizations under the Patient Safety and Quality Improvement Act of 2005. Citation Text: Dwyer PE, Watts CD. The benefits and burdens of working with patient safety organizations under the Patient Safety and Quality Imp…
  11. psnet.ahrq.gov/issue/comparison-traditional-trigger-tool-data-warehouse-based-screening-identifying-hospital
    June 11, 2010 - Study Comparison of traditional trigger tool to data warehouse based screening for identifying hospital adverse events. Citation Text: O'Leary KJ, Devisetty VK, Patel AR, et al. Comparison of traditional trigger tool to data warehouse based screening for identifying hospital adverse ev…
  12. www.ahrq.gov/cpi/about/otherwebsites/cds-connect/index.html
    June 01, 2019 - CDS Connect: Using Clinical Decision Support To Move Evidence Into Practice Project Summary CDS Connect is a key component of AHRQ’s recently launched initiative on clinical decision support (CDS) to move evidence into practice and to make CDS more patient centered. This initiative has four components:   …
  13. integrationacademy.ahrq.gov/news-and-events/news/behavioral-health-parity-new-rules-enforcement
    October 11, 2024 - An official website of the Department of Health & Human Services Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates The Academy Integrating Behavioral Health & Primary Care Expand Navi…
  14. 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. Copy C…
  15. digital.ahrq.gov/2020-year-review/research-summary/supporting-clinicians-improve-decision-making-and-patients-care-emerging-research
    January 01, 2020 - Supporting Clinicians to Improve Decision Making and Patients’ Care - Emerging Research Applying Digital Healthcare Solutions in Acute Settings Emergency departments (EDs) deliver high-volume patient care in hazardous decision-making environments fraught with excessive cognitive load…
  16. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/128-what-are-4es-one-pager.docx
    April 01, 2025 - The 4 Es framework identifies four important elements when implementing patient safety interventions: Engage, Educate, Execute, and Evaluate. This framework integrates well with the Comprehensive Unit-based Safety Program (CUSP) and addresses both the technical objectives of improving practices and the adaptive objecti…
  17. psnet.ahrq.gov/issue/health-system-resilience-accreditation-high-quality-care-and-continuous-quality-improvement
    November 25, 2020 - Commentary Health system resilience, accreditation, high-quality care, and continuous quality improvement: what is the destination and how do we get there? Citation Text: Nicklin W, Greenfield D. Health system resilience, accreditation, high-quality care, and continuous quality improveme…
  18. psnet.ahrq.gov/issue/framework-analysis-communication-errors-health-care
    October 21, 2020 - Commentary A framework for the analysis of communication errors in health care. Citation Text: Bender JA, Thiyagarajan S, Morrish W, et al. A framework for the analysis of communication errors in health care. J Patient Saf. 2025;21(2):69-81. doi:10.1097/pts.0000000000001303. Copy Citat…
  19. psnet.ahrq.gov/issue/eleven-basic-procedurespractices-dental-patient-safety
    March 27, 2013 - Commentary Eleven basic procedures/practices for dental patient safety. Citation Text: Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. Eleven basic procedures/practices for dental patient safety. J Patient Saf. 2020;16(1). doi:10.1097/pts.0000000000000234. Copy Citation For…
  20. www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-user-guide.pdf
    July 01, 2018 - Task Timeline for Project Planning for a Single Hospital………..…… .........................8 List of … This chapter is designed to guide you through the planning and decisionmaking stages of your project … Task Timeline for Project Planning for a Single Hospital Task Timeline for Project Planning Pl an … survey in-house or through an outside vendor, you will need to establish a project team responsible for planning … Their responsibilities will include the following:  Planning and budgeting—Determine the scope of