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psnet.ahrq.gov/issue/physician-communication-when-prescribing-new-medications
December 16, 2009 - Study
Physician communication when prescribing new medications.
Citation Text:
Tarn DM, Heritage J, Paterniti DA, et al. Physician communication when prescribing new medications. Arch Intern Med. 2006;166(17):1855-1862.
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psnet.ahrq.gov/issue/medication-reconciliation-acute-care-setting-opportunity-and-challenge-nursing
June 02, 2021 - Commentary
Medication reconciliation in the acute care setting: opportunity and challenge for nursing.
Citation Text:
Sullivan C, Gleason KM, Rooney D, et al. Medication reconciliation in the acute care setting: opportunity and challenge for nursing. J Nurs Care Qual. 2005;20(2):95-98.…
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psnet.ahrq.gov/issue/instrument-count-sheets-and-set-reviews-patient-safety-tools
February 28, 2011 - Commentary
Instrument count sheets and set reviews as patient safety tools.
Citation Text:
Spear J. Instrument Count Sheets and Set Reviews as Patient Safety Tools. AORN J. 2016;104(6):588-592. doi:10.1016/j.aorn.2016.10.007.
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psnet.ahrq.gov/issue/evaluating-teamwork-simulated-obstetric-environment
November 04, 2009 - Study
Evaluating teamwork in a simulated obstetric environment.
Citation Text:
Morgan PJ, Pittini R, Regehr G, et al. Evaluating teamwork in a simulated obstetric environment. Anesthesiology. 2007;106(5):907-915.
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psnet.ahrq.gov/issue/clinical-lab-quality-cms-and-survey-organization-oversight-should-be-strengthened
September 28, 2010 - Government Resource
Clinical Lab Quality: CMS and Survey Organization Oversight Should Be Strengthened.
Citation Text:
Clinical Lab Quality: CMS and Survey Organization Oversight Should Be Strengthened. Washington DC; Government Accountability Office; June 2006. Report no GAO-06-416.…
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psnet.ahrq.gov/issue/top-10-patient-safety-issues-what-more-can-we-do
May 08, 2013 - Commentary
Top 10 patient safety issues: what more can we do?
Citation Text:
Steelman VM, Graling PR. Top 10 patient safety issues: what more can we do? AORN J. 2013;97(6):679-98, quiz 699-701. doi:10.1016/j.aorn.2013.04.012.
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psnet.ahrq.gov/issue/misdiagnosis-dangerous-help-your-doctor-get-it-right
August 03, 2022 - Newspaper/Magazine Article
Misdiagnosis is dangerous. Help your doctor get it right.
Citation Text:
Terry K. Misdiagnosis is dangerous. Help your doctor get it right. WebMD. November 11, 2024;
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psnet.ahrq.gov/issue/overlooked-condition
October 03, 2018 - Newspaper/Magazine Article
An overlooked condition.
Citation Text:
Nicholas L. An overlooked condition. For diabetics, the hospital can be a dangerous place. Modern healthcare. 2005;35(46):24.
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www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-measures-atlas/ccrm-atlas-ex521.html
March 01, 2013 - Clinical-Community Relationships Measures (CCRM) Atlas
Exhibit 5-21. Measure 21: The effectiveness of communication between practice and community resource (GP-LI)
Previous Page Next Page
Table of Contents
Clinical-Community Relationships Measures (CCRM) Atlas
Introduction
Acknowledgments
1. W…
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psnet.ahrq.gov/issue/time-out-professional-and-organizational-ethics-speaking-or
November 08, 2017 - Commentary
Time-out: the professional and organizational ethics of speaking up in the OR.
Citation Text:
Berlinger N, Dietz E. Time-out: The Professional and Organizational Ethics of Speaking Up in the OR. AMA J Ethics. 2016;18(9):925-32. doi:10.1001/journalofethics.2016.18.9.stas1-1609.…
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psnet.ahrq.gov/issue/your-companys-secret-change-agents
June 09, 2021 - Commentary
Your company's secret change agents.
Citation Text:
Pascale RT, Sternin J. Your company's secret change agents. Harv Bus Rev. 2005;83(5):72-81, 153.
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psnet.ahrq.gov/issue/trends-adverse-events-over-time-why-are-we-not-improving
October 02, 2019 - Commentary
Trends in adverse events over time: why are we not improving?
Citation Text:
Shojania KG, Thomas EJ. Trends in adverse events over time: why are we not improving? BMJ Qual Saf. 2013;22(4):273-7. doi:10.1136/bmjqs-2013-001935.
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digital.ahrq.gov/ahrq-funded-projects/virtual-reality-point-care-increase-uptake-medications-opioid-use-disorder
September 30, 2023 - Virtual Reality at the Point of Care to Increase Uptake of Medications for Opioid Use Disorder (MOUD) in the Emergency Department
Project Description
Participating in an immersive virtual reality experience may increase willingness of emergency department patients with opioid u…
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www.ahrq.gov/cahps/surveys-guidance/helpful-resources/planning/Set-the-Stage-for-Conducting-the-Survey.html
December 01, 2019 - Step 5: Set the Stage for Conducting the Survey
Review all steps in the process of planning a survey project:
Step 1: Form a Project Team .
Step 2: Form an Advisory Group .
Step 3: Define Your Goals .
Step 4: Plan a Communications Strategy .
Step 5: Set the Stage for Conducting the Survey.
Step…
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www.ahrq.gov/sops/surveys/nursing-home/index.html
April 01, 2025 - SOPS Nursing Home Survey
AHRQ released the Surveys on Patient Safety Culture® (SOPS®) Nursing Home Survey to assess staff perceptions about patient safety culture in their nursing home in 2008. In 2025, AHRQ released a new version, the SOPS Nursing Home Survey 2.0 . This new version removed all negatively wo…
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digital.ahrq.gov/ahrq-funded-projects/use-ehr-metadata-assess-hospital-discharge-planning-post-acute-transitions
January 31, 2025 - Use of Electronic Health Record Metadata to Assess Hospital Discharge Planning for Post-Acute Transitions
Project Description
Publications
Analyzing electronic health record metadata may help health systems identify gaps, inconsistencies, and inefficiencies in discharge p…
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psnet.ahrq.gov/issue/transitioning-newborns-nicu-home-resource-toolkit
August 01, 2012 - Government Resource
Transitioning Newborns From NICU to Home: A Resource Toolkit.
Citation Text:
Transitioning Newborns From NICU to Home: A Resource Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; December 2013. AHRQ Publication No. 12(14)-0054-EF.
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psnet.ahrq.gov/issue/inpatient-notes-diagnostic-excellence-starts-incessant-watch
August 31, 2022 - Commentary
Inpatient notes: diagnostic excellence starts with an incessant watch.
Citation Text:
Dhaliwal G. Annals for Hospitalists Inpatient Notes - Diagnostic Excellence Starts With an Incessant Watch. Ann Intern Med. 2017;167(8):HO2-HO3. doi:10.7326/m17-2447.
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psnet.ahrq.gov/issue/policy-and-future-adverse-event-detection-using-information-technology
August 31, 2011 - Commentary
Policy and the future of adverse event detection using information technology.
Citation Text:
Bates DW, Evans S, Murff HJ, et al. Policy and the future of adverse event detection using information technology. J Am Med Inform Assoc. 2003;10(2):226-8.
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www.ahrq.gov/hai/cusp/toolkit/observing-rounds.html
December 01, 2012 - Observing Patient Care Rounds
CUSP Toolkit
Communication among disciplines can be improved if viewed through the eyes of an objective observer.
Problem statement: Interdisciplinary rounds are in the best interest of patients. Poor communication among staff is a root cause of many patient adverse and sentin…