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psnet.ahrq.gov/issue/recent-two-fold-increase-medical-adverse-event-deaths-among-us-inpatients
April 06, 2022 - Study
A recent two-fold increase in medical adverse event deaths among US inpatients.
Citation Text:
Oura P, Sajantila A. A recent two-fold increase in medical adverse event deaths among US inpatients. J Public Health Res. 2022;11(4):227990362211399. doi:10.1177/22799036221139935.
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psnet.ahrq.gov/issue/time-take-hearing-loss-seriously
September 23, 2020 - Commentary
Time to take hearing loss seriously.
Citation Text:
Blustein J, Wallhagen MI, Weinstein BE, et al. Time to take hearing loss seriously. Jt Comm J Qual Patient Saf. 2019;46(1):53-58. doi:10.1016/j.jcjq.2019.10.003.
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psnet.ahrq.gov/issue/improving-safety-evaluating-impact-supply-chain-and-drug-shortages-health-systems
November 04, 2020 - Commentary
Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems.
Citation Text:
Patel V, Cieslak K, Hertig JB. Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems. Hosp Pharm. 2023;58(2):120-124.…
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psnet.ahrq.gov/issue/adherence-national-guidelines-timeliness-test-results-communication-patients-veterans-affairs
March 03, 2019 - Study
Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system.
Citation Text:
Meyer AND, Scott TMT, Singh H. Adherence to national guidelines for timeliness of test results communication to patients in the Veter…
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psnet.ahrq.gov/issue/contributors-diagnostic-error-or-delay-acute-care-setting-survey-clinical-stakeholders
May 26, 2021 - Study
Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders.
Citation Text:
Redmond S, Barwise A, Zornes S, et al. Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders. Health Serv Insights…
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psnet.ahrq.gov/issue/quality-life-after-maternal-near-miss-systematic-review
November 24, 2021 - Study
Quality of life after maternal near miss: a systematic review.
Citation Text:
Rosen IEW, Shiekh RM, Mchome B, et al. Quality of life after maternal near miss: a systematic review. Acta Obstet Gynecol Scand. 2021;100(4):704-714. doi:10.1111/aogs.14128.
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psnet.ahrq.gov/issue/preventable-adverse-drug-events-hospitalized-patients-comparative-study-intensive-care-and
March 31, 2021 - Study
Classic
Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units.
Citation Text:
Cullen DJ, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients. Crit Care Me…
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digital.ahrq.gov/ahrq-funded-projects/using-health-information-technology-improve-transitions-complex-elderly/annual-summary/2011
January 01, 2011 - Using Health Information Technology to Improve Transitions of Complex Elderly Patients from Skilled Nursing Facilities (SNF) to Home - 2011
Project Name
Using Health Information Technology to Improve Transitions of Complex Elderly Patients from Skilled Nursing Facilities (SNF) to Home
Princi…
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psnet.ahrq.gov/issue/register-based-research-adverse-events-revealing-incomplete-records-threatening-patient
October 06, 2021 - Review
Register-based research of adverse events revealing incomplete records threatening patient safety.
Citation Text:
Kinnunen U-M, Kivekäs E, Palojoki S, et al. Register-based research of adverse events revealing incomplete records threatening patient safety. Stud Health Technol Info…
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www.ahrq.gov/news/newsroom/case-studies/ktcoe33.html
October 01, 2014 - Iowa Medicaid Uses AHRQ Research, Data to Improve Quality
Search All Impact Case Studies
March 2010
As a result of participating in the Medicaid Medical Directors Learning Network—an AHRQ Knowledge Transfer project—the Iowa Medicaid Enterprise, in consultation with the Iowa Foundation for Medical Care, used…
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psnet.ahrq.gov/issue/errors-breast-imaging-how-reduce-errors-and-promote-safety-environment
July 22, 2020 - Commentary
Errors in breast imaging: how to reduce errors and promote a safety environment.
Citation Text:
Sivarajah R, Dinh ML, Chetlen A. Errors in breast imaging: how to reduce errors and promote a safety environment. J Breast Imaging. 2021;3(2):221-230. doi:10.1093/jbi/wbaa118.
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www.ahrq.gov/news/events/nac/2018-03-nac/nacmtg0317-minutes.html
July 01, 2018 - that AHRQ is spending much time in coordinating across the various streams and attending to the five priorities
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case3.html
November 01, 2014 - This initiative began with the leadership studying the whole organization, defining priorities, identifying … time during their participation in Lean, many interviewees noted that competing responsibilities and priorities … Staff learn Lean skills on their own, but they keep other priorities in perspective.
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psnet.ahrq.gov/node/49695/psn-pdf
October 01, 2013 - Finding Fault With the Default Alert
October 1, 2013
Baysari M. Finding Fault With the Default Alert. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/finding-fault-default-alert
The Case
A 33-year-old man with known refractory epilepsy and developmental delay was admitted to the hospital
after experiencing …
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psnet.ahrq.gov/node/73554/psn-pdf
July 28, 2021 - EMS Patient Safety in the Field
July 28, 2021
Augustine JJ, Fitall E, Hall KK, et al. EMS Patient Safety in the Field. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/ems-patient-safety-field
Introduction
Emergency medical services (EMS) personnel serve a critical role within the care continuum. They ar…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-ve-supp-item-set-08-2022.pdf
January 01, 2022 - SOPS® Value and Efficiency Supplemental Items for the SOPS Hospital Survey - English
SOPS® Value and Efficiency Supplemental
Item Set for the SOPS Hospital Survey
Language: English
• Purpose: This supplemental item set was designed for use with the core SOPS® Hospital Survey Version 2.0
to help hospitals assess…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/value-efficiency-supplemental-item-english.pdf
March 01, 2023 - SOPS® Value and Efficiency Supplemental Item Set for the SOPS Medical Office Survey - English
SOPS® Value and Efficiency Supplemental Item
Set for the SOPS Medical Office Survey
Language: English
• Purpose: This supplemental item set was designed for use with the core SOPS® Medical Office
Survey to help medical…
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psnet.ahrq.gov/node/49805/psn-pdf
September 01, 2017 - The Forgotten Radiographic Read
September 1, 2017
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read
The Case
A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for
management of inferior…
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effectivehealthcare.ahrq.gov/sites/default/files/pulmonary-horizon-scan-high-impact-1506.pdf
October 01, 2015 - Vertex outlines 2015 business priorities to support
the development, approval and launch of new
medicines
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/Telediagnosis-brief2.pdf
August 03, 2020 - the use of telediagnosis from the massive expansion now in progress and identify emerging
research priorities