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psnet.ahrq.gov/issue/interventions-improve-employee-health-and-well-being-within-health-care-organizations
April 11, 2009 - Review
Interventions to improve employee health and well-being within health care organizations: a systematic review.
Citation Text:
Williams SP, Malik HT, Nicolay CR, et al. Interventions to improve employee health and well-being within health care organizations: A systematic review. J …
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psnet.ahrq.gov/issue/handoffs-causing-patient-harm-survey-medical-and-surgical-house-staff
July 10, 2008 - Study
Handoffs causing patient harm: a survey of medical and surgical house staff.
Citation Text:
Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34(10):563-70.
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www.ahrq.gov/talkingquality/translate/scores/adjustment-scoring.html
January 01, 2023 - Making Adjustments to Health Care Quality Scores
One of the most thorny topics in quality measurement is the adjustment of scores across different plans or providers to account for differences in the characteristics of their patients or themselves. This page reviews key issues related to adjustments to scores…
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psnet.ahrq.gov/issue/improved-pain-resolution-hospitalized-patients-through-targeting-pain-mismanagement-medical
March 24, 2019 - Study
Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error.
Citation Text:
Okon TR, Lutz PS, Liang H. Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error. J Pain Symptom Manage.…
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www.ahrq.gov/ncepcr/research-transform-primary-care/transform/cost/app-c.html
October 01, 2015 - Estimating the Costs of Primary Care Transformation: A Practical Guide and Synthesis Report
Appendix C. Methodological References Cited by Grantees
Previous Page
Table of Contents
Estimating the Costs of Primary Care Transformation: A Practical Guide and Synthesis Report
Background
A Practical…
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psnet.ahrq.gov/issue/patient-safety-external-beam-radiotherapy-guidelines-risk-assessment-and-analysis-adverse
March 15, 2017 - Study
Patient safety in external beam radiotherapy—guidelines on risk assessment and analysis of adverse error-events and near misses: introducing the ACCIRAD project.
Citation Text:
Malicki J, Bly R, Bulot M, et al. Patient safety in external beam radiotherapy - guidelines on risk asses…
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psnet.ahrq.gov/issue/combined-sna-and-lda-methods-understand-adverse-medical-events
November 15, 2023 - Journal Article
Combined SNA and LDA methods to understand adverse medical events
Citation Text:
Zhu L, Reychav I, McHaney R, et al. Combined SNA and LDA methods to understand adverse medical events. Int J Risk Saf Med. 2019;30(3):129-153. doi:10.3233/JRS-180052.
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
August 01, 2022 - Event Investigation and Analysis Guide: Appendix D
CANDOR Tool
PROCESS
QUESTIONS TO REVIEW
Y/N
CONTRIBUTING OR CAUSAL FACTOR Y/N
FINDINGS /
COMMENTS
COMMUNICATION
Did all caregivers have access to all pertinent information needed to make the best decisions for the patient? (e.g.,…
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psnet.ahrq.gov/issue/effect-resident-duty-hour-restriction-trauma-center-outcomes-teaching-hospitals-state
September 12, 2016 - Study
The effect of resident duty hour restriction on trauma center outcomes in teaching hospitals in the state of Pennsylvania.
Citation Text:
Helling TS, Kaswan S, Boccardo J, et al. The effect of resident duty hour restriction on trauma center outcomes in teaching hospitals in the st…
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psnet.ahrq.gov/issue/understanding-attitudes-hospital-pharmacists-reporting-medication-incidents-qualitative-study
September 04, 2016 - Study
Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study.
Citation Text:
Williams SD, Phipps D, Ashcroft DM. Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study. Res Social Adm…
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psnet.ahrq.gov/issue/national-trends-hospitalizations-opioid-poisonings-among-children-and-adolescents-1997-2012
January 16, 2019 - Study
National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012.
Citation Text:
Gaither JR, Leventhal JM, Ryan SA, et al. National Trends in Hospitalizations for Opioid Poisonings Among Children and Adolescents, 1997 to 2012. JAMA Peds. 2016;1…
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psnet.ahrq.gov/issue/misleading-one-detail-preventable-mode-diagnostic-error
February 10, 2016 - Study
Misleading one detail: a preventable mode of diagnostic error?
Citation Text:
Arzy S, Brezis M, Khoury S, et al. Misleading one detail: a preventable mode of diagnostic error? J Eval Clin Pract. 2009;15(5):804-6. doi:10.1111/j.1365-2753.2008.01098.x.
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psnet.ahrq.gov/issue/reducing-near-miss-medication-events-using-evidence-based-approach
July 07, 2021 - Study
Reducing near miss medication events using an evidence-based approach.
Citation Text:
Smith-Love J. Reducing near miss medication events using an evidence-based approach. J Nurs Care Qual. 2022;37(4):327-333. doi:10.1097/ncq.0000000000000630.
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DOI…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-88-measure-1-section-2-attachment-5.pdf
June 02, 2025 - Measure 1, Section 2, Attachment 5
DET Quality Analysis Criteria Lurie_Bobb Lutheran_Gupta Stroger_Garcia FAQ Guidance Document
a. All cells should be filled out, even if
“N/A” a
I would recommend that the site
complete all fields in the "Element",
"Question", and "Measure" tabs a
n/a
b. EHR Data source appli…
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/recruitment-brochure-nc.pdf
January 01, 2003 - Heart Health NOW
This is our time!
Are you ready?
Heart Health NOW!
Advancing heart health in
N.C. primary care
Heart Health NOW! is the N.C. Cooperative of
EvidenceNOW —a program funded by the
Agency for Healthcare Research and Quality
Your practice will partner with us by:
• Establishing an EHR connection…
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-89-adhd-behavior-section-2-attach-4.pdf
June 02, 2025 - Section 2, Attachment 4
DET Quality Analysis Criteria Lurie_Bobb Lutheran_Gupta Stroger_Garcia FAQ Guidance Document
a. All cells should be filled out, even if
“N/A” a
I would recommend that the site
complete all fields in the "Element",
"Question", and "Measure" tabs a
n/a
b. EHR Data source application (Doe…
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psnet.ahrq.gov/issue/no-harm-found-when-nurse-anesthetists-work-without-supervision-physicians
August 04, 2021 - Study
No harm found when nurse anesthetists work without supervision by physicians.
Citation Text:
Dulisse B, Cromwell J. No harm found when nurse anesthetists work without supervision by physicians. Health Aff (Millwood). 2010;29(8):1469-1475. doi:10.1377/hlthaff.2008.0966.
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psnet.ahrq.gov/issue/struggling-invent-high-reliability-organizations-health-care-settings-insights-field
October 02, 2019 - Study
Struggling to invent high-reliability organizations in health care settings: insights from the field.
Citation Text:
Dixon NM, Shofer M. Struggling to invent high-reliability organizations in health care settings: Insights from the field. Health Serv Res. 2006;41(4 Pt 2):1618-32.…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/visual-slides.html
June 01, 2017 - Management Practices for Sustainability Module 5: Visual Management
Slide 1: Management Practices for Sustainability Module 5: Visual Management
Management Practices for Sustainability
Module 5: Visual Management
Slide 2: A Frontline Management System To Promote Safety Standard Work
Image: This imag…
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psnet.ahrq.gov/issue/meaningful-use-stage-2-e-prescribing-threshold-and-adverse-drug-events-medicare-part-d
July 05, 2017 - Study
Meaningful Use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population with diabetes.
Citation Text:
Powers C, Gabriel MH, Encinosa W, et al. Meaningful use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population w…