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www.ahrq.gov/patient-safety/resources/learning-lab/ehrll-long-desc.html
April 01, 2022 - Engineering High Reliability Learning Lab (EHRLL)
Principal Investigator: Sara Singer, Ph.D., Harvard University, Cambridge, MA
AHRQ Grant No.: HS24453
Project Period: 09/30/15–09/29/21
Description: The goal of this learning lab was to enhance capacity for innovation and develop highly reliable system…
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digital.ahrq.gov/2019-year-review/executive-summary
January 01, 2019 - Executive Summary
We are at the beginning of a digital revolution in healthcare, and it’s an exciting time with the potential for innovative whole-person care, data- and evidence-based solutions, and improvements in the healthcare system. The evolution of technology and digitization of d…
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integrationacademy.ahrq.gov/about/initiatives/opioid/grantees/pennsylvania
August 01, 2023 - An official website of the Department of Health & Human Services
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Integrating Behavioral Health & Primary Care
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digital.ahrq.gov/2020-year-review/executive-summary
January 01, 2020 - Executive Summary
In early 2020, the burdens of the global COVID-19 pandemic forced society to shut down and disrupted our healthcare system within the span of a few weeks. Fortunately, the application of digital healthcare technologies and digital practices in healthcare—such as artificial …
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - Alert Fatigue
Citation Text:
Alert Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
January 01, 2024 - Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS)
Final Report
APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS)
Principal Investigator: Wilson D. Pace, MD*
Key Personnel: David West, PhD *
Deborah S. Main, PhD*
John Westfall, MD*
Daniel Harris, PhD**
Organizational Aff…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/main-apps-surv-report-3-acute-pain.pdf
June 01, 2022 - Being prescribed an opioid for acute low back
pain or postoperative pain was associated with increased … likelihood of use of opioids at long-
term followup versus not being prescribed, based on observational … care, another opioid, nonopioid drug, or
noninvasive, nonpharmacological therapy, no
opioid/nothing prescribed … patient-specific
opioid prescribing and tapering protocol is
associated with a decrease in total opioid
dose prescribed
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integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/what-not-do
June 01, 2022 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
Contact Us
Español
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The Academy
Integrating Behavioral Health & Primary Care
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/involving-patients-families-in-safety-slides.pdf
July 25, 2023 - Involving Patients and Families in Safety: Slide Presentation
The National Action Alliance to Advance Patient
Safety Summer Webinar Series
Involving Patients and Families in Safety
July 25, 2023
2:00-3:00 PM ET
Special Guest Speakers
Sue Sheridan,
MIM, MBA, DHL
Founding Member,
Patients For Patient
Safety U…
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psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
December 01, 2017 - Unexpected Drawbacks of Electronic Order Sets
Citation Text:
McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - Diagnostic Overshadowing Dangers
Citation Text:
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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www.ahrq.gov/sites/default/files/2025-03/singer-benneyan-phillips-report.pdf
January 01, 2025 - Final Progress Report: Engineering Highly Reliable Communication and Coordination Systems for High-Risk Patients, Referrals, and Tests
1
Title Page
Final Progress Report
Engineering Highly Reliable Communication and Coordination Systems for High-Risk Patients,
Referrals, and Tests
Principal Investigators
Sar…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/7ZSKduUYHWKe7q_tTY9xbF
April 01, 2013 - Adherence is the extent to which a
patient acts in accordance with the prescribed interval and
dose of … Of 350 physicians responding to a mailed survey, 27%
had prescribed tamoxifen for breast cancer risk … including family medicine,
obstetrics and gynecology,
and general internal medicine
47% 350 96 (27%) prescribed … Women aged �35 y with a 5-y
risk for breast cancer �1.7%;
mean age, 52 y
82% (129/158) 129 37 (29%) prescribed … with raloxifene;
0 prescribed with
tamoxifen§
209/382 (54.7%) 171/382 (44.8%)
Kaplan et al,
2012 (
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/future05-breastcancer-10-5-2010final.pdf
September 01, 2010 - Reporting all harmful effects of
medications prescribed to reduce breast cancer
risk.
88.9%
(8) … Ascertainment of adverse effects of
medications prescribed to reduce breast cancer
risk (please discuss … patients are
working together to decide if medications to
reduce risk of breast cancer should be
prescribed … patients are
working together to decide if medications to
reduce risk of breast cancer should be
prescribed
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www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast3-gandhi.pdf
January 01, 2018 - New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - Optimizing (Gandhi)
Optimizing
the Use of HIT
to Improve
Safety
Tejal Gandhi
Handwriting
16
Ways IT Can Improve Safety
• Prevent errors and adverse events
• Facilitating a more rapid response after an
…
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www.ahrq.gov/evidencenow/projects/heart-health/evidence/aspirin.html
March 01, 2021 - Aspirin Use Evidence and Resources
A substantial body of evidence shows that taking aspirin can help patients lower their risk of heart attack or stroke. Patients with heart disease or who have had a stroke in the past are at high risk for having a heart attack or another stroke. Taking an aspirin every day can…
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www.ahrq.gov/topics/care-coordination.html
January 01, 2014 - Care Coordination
Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences are known ahead of time a…
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psnet.ahrq.gov/issue/gross-negligence-manslaughter-and-doctors-ethical-concerns-following-case-dr-bawa-garba
May 01, 2024 - Commentary
Gross negligence manslaughter and doctors: ethical concerns following the case of Dr Bawa-Garba.
Citation Text:
Samanta A, Samanta J. Gross negligence manslaughter and doctors: ethical concerns following the case of Dr Bawa-Garba. J Med Ethics. 2019;45(1):10-14. doi:10.1136/me…
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psnet.ahrq.gov/issue/culture-trauma-team-relation-human-factors
February 22, 2023 - Study
The culture of a trauma team in relation to human factors.
Citation Text:
Cole E, Crichton N. The culture of a trauma team in relation to human factors. J Clin Nurs. 2006;15(10). doi:10.1111/j.1365-2702.2006.01566.x.
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psnet.ahrq.gov/issue/state-science-human-factors-and-ergonomics-healthcare
April 01, 2015 - Commentary
State of science: human factors and ergonomics in healthcare.
Citation Text:
Hignett S, Carayon P, Buckle P, et al. State of science: human factors and ergonomics in healthcare. Ergonomics. 2013;56(10):1491-503. doi:10.1080/00140139.2013.822932.
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