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psnet.ahrq.gov/node/73371/psn-pdf
June 09, 2021 - Reducing failures in daily medical practice: healthcare
failure mode and effect analysis combined with computer
simulation.
June 9, 2021
Leeftink AG, Visser J, de Laat JM, et al. Reducing failures in daily medical practice: healthcare failure mode
and effect analysis combined with computer simulation. Ergonomics. …
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psnet.ahrq.gov/node/851349/psn-pdf
July 12, 2023 - Contributory factors and patient harm including deaths
associated direct acting oral anticoagulants (DOACs)
medication incidents: evaluation of real world data
reported to the national reporting and learning system.
July 12, 2023
Rowily AA, Jalal Z, Paudyal V. Contributory factors and patient harm including deaths…
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psnet.ahrq.gov/node/46083/psn-pdf
April 26, 2017 - Impact of commercial computerized provider order entry
(CPOE) and clinical decision support systems (CDSSs) on
medication errors, length of stay, and mortality in
intensive care units: a systematic review and meta-
analysis.
April 26, 2017
Prgomet M, Li L, Niazkhani Z, et al. Impact of commercial computerized pro…
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psnet.ahrq.gov/node/60812/psn-pdf
January 01, 2021 - A clinical pharmacist-led integrated approach for
evaluation of medication errors among medical intensive
care unit patients.
August 19, 2020
Aghili M, Neelathahalli Kasturirangan M. A clinical pharmacist-led integrated approach for evaluation of
medication errors among medical intensive care unit patients. JBI Ev…
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psnet.ahrq.gov/node/37446/psn-pdf
January 06, 2017 - How useful are voluntary medication error reports? The
case of warfarin-related medication errors.
January 6, 2017
Zhan C, Smith SR, Keyes MA, et al. How useful are voluntary medication error reports? The case of
warfarin-related medication errors. Jt Comm J Qual Patient Saf. 2008;34(1):36-45.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/39252/psn-pdf
August 08, 2010 - Where errors occur in the preparation and administration
of intravenous medicines: a systematic review and
Bayesian analysis.
August 8, 2010
McDowell SE, Mt-Isa S, Ashby D, et al. Where errors occur in the preparation and administration of
intravenous medicines: a systematic review and Bayesian analysis. Qual Saf …
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psnet.ahrq.gov/node/42399/psn-pdf
December 29, 2014 - Information technology interventions to improve
medication safety in primary care: a systematic review.
December 29, 2014
Lainer M, Mann E, Sönnichsen A. Information technology interventions to improve medication safety in
primary care: a systematic review. Int J Qual Health Care. 2013;25(5):590-8. doi:10.1093/intq…
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psnet.ahrq.gov/node/46696/psn-pdf
January 10, 2018 - Achieving the Institute of Medicine's 6 aims for quality in
the midst of the opioid crisis: considerations for the
emergency department.
January 10, 2018
Waszak DL, Fennimore LA. Achieving the Institute of Medicine's 6 aims for quality in the midst of the opioid
crisis: considerations for the emergency department.…
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psnet.ahrq.gov/node/34685/psn-pdf
September 29, 2017 - The urgent need to improve health care quality. Institute
of Medicine National Roundtable on Health Care Quality.
September 29, 2017
Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National
Roundtable on Health Care Quality. JAMA. 1998;280(11):1000-1005.
https://psnet.a…
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psnet.ahrq.gov/node/74029/psn-pdf
January 01, 2022 - Patient safety strategies in psychiatry and how they
construct the notion of preventable harm: a scoping
review.
November 3, 2021
Svensson J. Patient safety strategies in psychiatry and how they construct the notion of preventable harm:
a scoping review. J Patient Saf. 2022;18(3):245-252. doi:10.1097/pts.000000000…
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July 05, 2022 - Search All AHRQ Sites
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-high-risk-drugs-rapid-response.pdf
January 01, 2024 - For those newly prescribed an anticoagulant, the incident rate was about 22
hemorrhagic events per 100 … the therapy and, consequently, with
the control of INR.”28
Kapoor 202029 randomized 162 patients prescribed … healthcare system
United States
162 adults with a new
episode of venous
thromboembolism and
prescribed … have been
designed primarily for
use by PCPs in the
system)
United States
4,311 patients
prescribed … Impact of a smartphone app reminder on
adherence to aspirin prescribed as antithrombotic therapy.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/mhs/cahps-outpatient-mental-health-guidance.pdf
December 01, 2024 - Did the person who prescribed your mental health medicine also provide
you with any mental health counseling … 2
Did the person who prescribed your mental health medicine also
provide you with any mental health
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/2014-women-chartbook.pdf
January 01, 2014 - Overall Rate: In 2012, 1.5% of adults age 65 and over were prescribed at least 1 medication
from … Trends:
■ From 2002 to 2012, the percentage of adults age 65 and over who were prescribed at … ■ From 2002 to 2012, the percentage of men age 65 and over who were prescribed at least
1 medication … Prescription medications received include all prescribed medications initially purchased or
otherwise … Prescription medications received include all prescribed medications initially purchased or
otherwise
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/apcd/apcd-inventory.xlsx
October 01, 2015 - No
Cross-cutting Medications Utilization Not applicable Top 15 Pharmaceutical Classifications Prescribed … No
Cross-cutting Medications Utilization Not applicable Top 15 Pharmaceutical Classifications Prescribed … No
Mental health and substance abuse ADHD Quality Process Follow-Up Care for Children Prescribed ADHD … No
Mental health and substance abuse Depression Utilization Not applicable Percentage of Persons Prescribed … applicable Comparison of Antidepressant Usage and Claims by Clinical Risk Group (CRG) Among Persons Prescribed
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effectivehealthcare.ahrq.gov/sites/default/files/arthritis-horizon-scan-high-impact-1512.pdf
December 29, 2015 - additionally, corticosteroids
and biologic tumor necrosis factor (TNF)-alpha inhibitors may also be prescribed … An estimated 10% of patients with chronic gout could be prescribed lesinurad,
according to an April … also used
in patients with recurrent acute flares or chronic gout.32,33 Corticosteroids may also be prescribed … One clinician noted that patients receiving tofacitinib may be prescribed baricitinib
instead, due … The experts commented that the estimated costs were substantial, especially if
baricitinib is prescribed
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www.uspreventiveservicestaskforce.org/uspstf/document/published-comments-and-response/aspirin-for-the-prevention-of-cardiovascular-disease-preventive-medication-2009
October 15, 2009 - This low-risk patient, according to the USPSTF would be prescribed preventive aspirin.
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-module-2-slides.pptx
June 02, 2025 - Role modeling and effective cuing of team members to use prescribed teamwork behaviors and skills.
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-150-section-5-appendix-1-tables-1-5.pdf
October 22, 2013 - Summary recommendation: All children prescribed AAAs should be monitored for metabolic side effects at
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb5txt.html
December 01, 2017 - wheelchair
__ Check brakes and instruct pt on use
__ Seating modifications
__ Use all prescribed