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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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digital.ahrq.gov/sites/default/files/docs/hit-aging-adults-slides-071717.pdf
July 17, 2017 - A National Web Conference on the Use of Health IT to Improve Care Planning and Communication With Aging Adults - Slides
1
A National Web Conference on
the Use of Health IT to Improve
Care Planning and Communication
With Aging Adults
Presented by:
David H. Gustafson, Ph.D.
Charles Safran, M.D., M.S., FACMI
Kevi…
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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - Medication Administration Errors
Citation Text:
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - Personal Health Literacy
Citation Text:
Bakerjian D. Personal Health Literacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/item-sets/literacy/about_the_health_literacy_item_set_for_hospitals_911.pdf
October 01, 2015 - About the CAHPS® Health Literacy Item Set for Hospitals
CAHPS® Adult Hospital Survey: Supplemental Items
About the CAHPS Health Literacy Item Set for Hospitals
Document No. 911
10/01/2015
About the CAHPS® Health Literacy Item
Set for Hospitals
Introduction...............................................…
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pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
January 01, 2019 - Adverse and Temporary Harm Events in Long-Term-Care Hospitals (LTCH) Designated in Office of Inspector General Report1 as Clearly Preventable or Likely Preventable, by Clinical Category
Page 1 of 9
Adverse and Temporary Harm Events in Long-Term-Care
Hospitals (LTCH) Designated in Office of Inspector General
Report…
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effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/standardized-library-depression-white-paper.pdf
May 01, 2020 - Research White Paper: Standardized Library of Depression Outcome Measures
Research White Paper
Standardized Library of Depression Outcome
Measures
Research White Paper
Standardized Library of Depression Outcome
Measures
Prepared for:
Agency for Healthcare Research and Qual…
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psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities
Citation Text:
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - Root Cause Analysis Gone Wrong
Citation Text:
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/communication/strategy6kculturalcompetence.html
March 01, 2020 - Strategy 6K: Cultivating Cultural Competence
Contents
6.K.1. The Problem
6.K.2. Interventions
6.K.2.a. Maintaining Complete and Accurate Information on Enrollees
6.K.2.b. Building a Provider Network to Meet the Community’s Linguistic and Cultural Needs
6.K.2.c. Training Providers on Cultural…
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
Citation Text:
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
November 13, 2024 - The Second Victim Phenomenon: A Harsh Reality of Health Care Professions
Susan D. Scott RN, MSN | May 1, 2011
View more articles from the same authors.
Citation Text:
Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [intern…
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psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care
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December 23, 2020
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www.ahrq.gov/sites/default/files/wysiwyg/data/3P-RD-Data-Dictionary.xlsx
June 02, 2025 - 3P_RD_AHRQ_PUF_Data_Dictionary
README
Physician Practice Research Database (3P-RD) Data Dictionary
Purpose of the 3P-RD Database
The purpose of the Physician and Physician Practice Research Databases (3P-RD) is to create a prototype database to address gaps in current physician and physician practice data at the s…
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - Personal Health Literacy
August 30, 2023
Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/personal-health-literacy
Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in
August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…
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digital.ahrq.gov/ahrq-funded-projects/clinical-decision-support-optimizing-necrotizing-enterocolitis-prevention
January 01, 2023 - Clinical Decision Support Optimizing Necrotizing Enterocolitis Prevention Implementation in Neonatal Intensive Care Unit
Project Final Report ( PDF , 951.03 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for…
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psnet.ahrq.gov/web-mm/code-status-confusion
September 01, 2006 - SPOTLIGHT CASE
Code Status Confusion
Citation Text:
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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www.ahrq.gov/action-alliance/resources/type-harm.html
July 01, 2025 - Resources by Safety Topic
Contents Diagnostic Safety Emergency Preparedness Falls Healthcare-Associated Infections Maternal Safety Medication Safety Never Events Opioid Safety Pressure Ulcers Readmissions Sepsis Surgical Safety Transitions in Care Venous Thromboembolism Diagnostic Safety AHRQ Diagnostic Steward…
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psnet.ahrq.gov/web-mm/worst-headache
July 01, 2016 - The Worst Headache
Citation Text:
Edlow JA. The Worst Headache. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - Coming Undone: Failure of Closure Device
Citation Text:
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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