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  1. Parenteral nutrition errors and potential errors reported over the past 10 years. | PSNet

    psnet.ahrq.gov/issue/parenteral-nutrition-errors-and-potential-errors-reported-over-past-10-years
    June 20, 2018 - Study Parenteral nutrition errors and potential errors reported over the past 10 years. Citation Text: Guenter P, Ayers P, Boullata JI, et al. Parenteral Nutrition Errors and Potential Errors Reported Over the Past 10 Years. Nutr Clin Pract. 2017;32(6):826-830. doi:10.1177/08845336177158…

  2. Introduction | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-1.html
    June 01, 2020 - Operational Measurement of Diagnostic Safety: State of the Science Introduction Previous Page Next Page Table of Contents Operational Measurement of Diagnostic Safety: State of the Science Introduction Special Considerations for Measurement of Diagnostic Safety Getting Ready for Measurement: O…

  3. Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery: a review of 1200 consecutive cases. | PSNet

    psnet.ahrq.gov/issue/duration-anesthesia-indicator-morbidity-and-mortality-office-based-facial-plastic-surgery
    March 19, 2018 - Study Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery: a review of 1200 consecutive cases. Citation Text: Gordon NA, Koch ME. Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surger…

  4. Five new ways to advance diagnostic safety in your clinical practice. | PSNet

    psnet.ahrq.gov/issue/five-new-ways-advance-diagnostic-safety-your-clinical-practice
    June 30, 2021 - Commentary Five new ways to advance diagnostic safety in your clinical practice. Citation Text: Five new ways to advance diagnostic safety in your clinical practice. Bradford A, Goeschel C, Shofer M, et al. Am Fam Physician. 2023;108(1):14-16. Copy Citation Save …

  5. HIPAA and patient care: the role for professional judgment. | PSNet

    psnet.ahrq.gov/issue/hipaa-and-patient-care-role-professional-judgment
    June 22, 2022 - Commentary HIPAA and patient care: the role for professional judgment. Citation Text: Lo B, Dornbrand L, Dubler NN. HIPAA and patient care: the role for professional judgment. JAMA. 2005;293(14):1766-71. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML En…

  6. Job Aid: Introduction to Quality Improvement (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-intro-qi.pdf
    June 02, 2025 - Job Aid: Introduction to Quality Improvement Primary Care Practice Facilitator Training Series 1 Job Aid: Introduction to Quality Improvement Quality Improvement (QI) Basics The QI Process You will be helping practices to:  Identify areas for improvement.  Set goals.  Develop a plan that…

  7. Safe labeling practices to minimize medication errors in anesthesia: 5 case reports and review of the literature. | PSNet

    psnet.ahrq.gov/issue/safe-labeling-practices-minimize-medication-errors-anesthesia-5-case-reports-and-review
    March 26, 2014 - Commentary Safe labeling practices to minimize medication errors in anesthesia: 5 case reports and review of the literature. Citation Text: Prakash S, Mullick P, Kumar A, et al. Safe Labeling Practices to Minimize Medication Errors in Anesthesia. A & A Practice. 2017;10(10). doi:10.1213/…

  8. Implementing computerized physician order management at a community hospital. | PSNet

    psnet.ahrq.gov/issue/implementing-computerized-physician-order-management-community-hospital
    November 16, 2022 - Commentary Implementing computerized physician order management at a community hospital. Citation Text: Kraus S, Barber TR, Briggs B, et al. Implementing computerized physician order management at a community hospital. Jt Comm J Qual Patient Saf. 2008;34(2):74-84. Copy Citation For…

  9. Enhanced morbidity and mortality meeting and patient safety education for specialty trainees. | PSNet

    psnet.ahrq.gov/issue/enhanced-morbidity-and-mortality-meeting-and-patient-safety-education-specialty-trainees
    December 31, 2012 - Study Enhanced morbidity and mortality meeting and patient safety education for specialty trainees. Citation Text: Singh HP, Durani P, Dias JJ. Enhanced Morbidity and Mortality Meeting and Patient Safety Education for Specialty Trainees. J Patient Saf. 2019;15(1):37-48. doi:10.1097/PTS.0…

  10. Building nursing intellectual capital for safe use of information technology: a systematic review. | PSNet

    psnet.ahrq.gov/issue/building-nursing-intellectual-capital-safe-use-information-technology-systematic-review
    June 23, 2009 - Review Building nursing intellectual capital for safe use of information technology: a systematic review. Citation Text: Poe SS. Building nursing intellectual capital for safe use of information technology: a systematic review. J Nurs Care Qual. 2011;26(1):4-12. doi:10.1097/NCQ.0b013e31…

  11. Patient safety in home hemodialysis: quality assurance and serious adverse events in the home setting. | PSNet

    psnet.ahrq.gov/issue/patient-safety-home-hemodialysis-quality-assurance-and-serious-adverse-events-home-setting
    January 23, 2017 - Commentary Patient safety in home hemodialysis: quality assurance and serious adverse events in the home setting. Citation Text: Pauly RP, Eastwood DO, Marshall MR. Patient safety in home hemodialysis: quality assurance and serious adverse events in the home setting. Hemodial Int. 2015;1…

  12. Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. | PSNet

    psnet.ahrq.gov/issue/chronicle-pandemic-foretold-learning-covid-19-failure-next-outbreak-arrives
    June 08, 2022 - Newspaper/Magazine Article Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. Citation Text: Osterholm MT, Olshaker M. Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. Foreign Affair…

  13. American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology. | PSNet

    psnet.ahrq.gov/issue/american-college-endocrinology-and-american-association-clinical-endocrinologists-position
    August 20, 2018 - Commentary American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology. Citation Text: Bates DW, Clark NG, Cook RI, et al. American College of Endocrinology and Amer…

  14. Critical conversations: a call for a nonprocedural "time out." | PSNet

    psnet.ahrq.gov/issue/critical-conversations-call-nonprocedural-time-out
    February 18, 2011 - Commentary Critical conversations: a call for a nonprocedural "time out." Citation Text: Sehgal NL, Fox M, Sharpe B, et al. Critical conversations: a call for a nonprocedural "time out". J Hosp Med. 2011;6(4):225-30. doi:10.1002/jhm.853. Copy Citation Format: DOI Google Sch…

  15. Understanding Development Methods from Other Industries to Improve the Design of Consumer Health IT - 2010 | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/understanding-development-methods-other-industries-improve-design-consumer/annual-summary/2010
    January 01, 2010 - Understanding Development Methods from Other Industries to Improve the Design of Consumer Health IT - 2010 Project Name Understanding Development Methods from Other Industries to Improve the Design of Consumer Health Information Technology Principal Investigator Montague, Enid Or…

  16. Brownbridge G et al. 1986 "An interactive computerized protocol for the management of hypertension: effects on the general-practitioner's clinical behavior." | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/brownbridge-g-et-al
    January 01, 2023 - Brownbridge G et al. 1986 "An interactive computerized protocol for the management of hypertension: effects on the general-practitioner's clinical behavior." Reference Brownbridge G, Evans A, Fitter M, et al. An interactive computerized protocol for the management of hypertension: effects on the gener…

  17. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. | PSNet

    psnet.ahrq.gov/issue/pain-management-and-opioid-epidemic-balancing-societal-and-individual-benefits-and-risks
    March 29, 2006 - Book/Report Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Citation Text: Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Bonnie RJ, Ford M…

  18. Kuilboer MM et al. 2006 "Computed critiquing integrated into daily clinical practice affects physicians' behavior - a randomized clinical trial with AsthmaCritic." | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/kuilboer-mm-et-al-2006
    January 01, 2006 - Kuilboer MM et al. 2006 "Computed critiquing integrated into daily clinical practice affects physicians' behavior - a randomized clinical trial with AsthmaCritic." Reference Kuilboer MM, van Wijk MAM, Mosseveld M, et al. Computed critiquing integrated into daily clinical practice affects physicians' b…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848108/psn-pdf
    April 26, 2023 - The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. April 26, 2023 Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/do…

  20. Disposition of Comments for Technical Brief 35: Asthma Self-Management Education Packages (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/tech-brief-35-asthma-self-management-comments.pdf
    April 27, 2020 - Disposition of Comments for Technical Brief 35: Asthma Self-Management Education Packages Technical Brief Disposition of Comments Report Research Review Title: Characteristics of Existing Asthma Self-Management Education Packages Draft report available for public comment from November 26, 2019, …
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