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6181. Assess Your Health Care Quality Reporting Project | Agency for Healthcare Research and Quality
      www.ahrq.gov/talkingquality/assess/index.html
      September 01, 2019 - Assess Your Health Care Quality Reporting Project Reporting comparative quality information to consumers is typically not a one-time event but an ongoing activity. For this reason, evaluation is a key part of your work, an aspect that has to be thought about and, in some cases, acted upon from the outset. An …

6182. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43791/psn-pdf
      December 17, 2014 - Facilitating Patient Understanding of Discharge Instructions: Workshop Summary. December 17, 2014 Alper J, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; December 2014. ISBN: 9780309307383. https:…

6183. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45383/psn-pdf
      August 31, 2016 - Case report of a medication error: in the eye of the beholder. August 31, 2016 Naunton M, Nor K, Bartholomaeus A, et al. Case report of a medication error. Medicine (Baltimore). 2016;95(28):e4186. doi:10.1097/md.0000000000004186. https://psnet.ahrq.gov/issue/case-report-medication-error-eye-beholder Look-alike dr…

6184. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46159/psn-pdf
      May 31, 2017 - Despite technology, verbal orders persist, read back is not widespread, and errors continue. May 31, 2017 ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4. https://psnet.ahrq.gov/issue/despite-technology-verbal-orders-persist-read-back-not-widespread-and- errors-continue Verbal orders are kno…

6185. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43997/psn-pdf
      August 02, 2015 - Sentinel events, serious reportable events, and root cause analysis. August 2, 2015 Chen TC, Schein OD, Miller JW. Sentinel events, serious reportable events, and root cause analysis. JAMA Ophthalmol. 2015;133(6):631-632. doi:10.1001/jamaophthalmol.2015.0672. https://psnet.ahrq.gov/issue/sentinel-events-serious-re…

6186. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74858/psn-pdf
      February 23, 2022 - Improving responses to safety incidents: we need to talk about justice. February 23, 2022 Cribb A, O'Hara JK, Waring J. Improving responses to safety incidents: we need to talk about justice. BMJ Qual Saf. 2022;31(4):327-330. doi:10.1136/bmjqs-2021-014333. https://psnet.ahrq.gov/issue/improving-responses-safety-in…

6187. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48039/psn-pdf
      August 07, 2019 - Utilization of a role-based head covering system to decrease misidentification in the operating room. August 7, 2019 Rosen DA, Criser AL, Petrone AB, et al. Utilization of a Role-Based Head Covering System to Decrease Misidentification in the Operating Room. J Patient Saf. 2019;15(4):e90-e93. doi:10.1097/PTS.00000…

6188. Using Data to Reduce Disparities and Improve Quality | Agency for Healthcare Research and Quality
      www.ahrq.gov/evidencenow/tools/reduce-disparities.html
      February 01, 2025 - Using Data to Reduce Disparities and Improve Quality Resource: Using Data to Reduce Disparities and Improve Quality: A Guide for Health Care Organizations (PDF, 1 MB; 14 pages) This brief recommends strategies that primary care practices and health care organizations can use to effectively organize and inter…

6189. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46386/psn-pdf
      April 03, 2018 - The impact of electronic health records on diagnosis. April 3, 2018 Graber ML, Byrne C, Johnston D. The impact of electronic health records on diagnosis. Diagnosis (Berl). 2017;4(4):211-223. doi:10.1515/dx-2017-0012. https://psnet.ahrq.gov/issue/impact-electronic-health-records-diagnosis Health information technol…

6190. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46554/psn-pdf
      October 25, 2017 - Severe hyperglycemia in patients incorrectly using insulin pens at home. October 25, 2017 National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. October 12, 2017. https://psnet.ahrq.gov/issue/severe-hyperglycemia-patients-incorrect…

6191. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840169/psn-pdf
      November 16, 2022 - ISMP survey on tall man (mixed case) lettering to reduce drug name confusion. November 16, 2022 Institute for Safe Medication Practices. https://psnet.ahrq.gov/issue/ismp-survey-tall-man-mixed-case-lettering-reduce-drug-name-confusion Mixed case letters are one suggested strategy to reduce look-alike medication na…

6192. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837214/psn-pdf
      May 25, 2022 - Global Report on Infection Prevention and Control: Executive Summary. May 25, 2022 Geneva, Switzerland; World Health Organization; May 5, 2022. https://psnet.ahrq.gov/issue/global-report-infection-prevention-and-control-executive-summary Healthcare-acquired infection is a persistent systemic problem. This report r…

6193. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44787/psn-pdf
      January 20, 2016 - Medication errors involving overrides of healthcare technology. January 20, 2016 Grissinger M. PA-PSRS Patient Saf Advis. December 2015;12:141-148. https://psnet.ahrq.gov/issue/medication-errors-involving-overrides-healthcare-technology Users often bypass alerts meant to enhance safety of medication ordering and d…

6194. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45673/psn-pdf
      December 07, 2016 - Report on the Safe Use of Pick Lists in Ambulatory Care Settings. December 7, 2016 Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016. https://psnet.ahrq.gov/issue/report-safe-use-pick-lists-ambulatory-care-settings Standard term selection tools—like pick lists or drop-d…

6195. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852284/psn-pdf
      August 09, 2023 - ‘Medical errors are the third leading cause of death’ and other statistics you should question. August 9, 2023 Jaklevic MC. HealthJournalism.org. July 27, 2023. https://psnet.ahrq.gov/issue/medical-errors-are-third-leading-cause-death-and-other-statistics-you-should- question Published rates of medical errors con…

6196. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74129/psn-pdf
      January 01, 2022 - Factors influencing providers' willingness to deprescribe medications. December 1, 2021 Davila H, Rosen AK, Stolzmann K, et al. Factors influencing providers' willingness to deprescribe medications. J Am Coll Clin Pharm. 2022;5:15-25. doi:10.1002/jac5.1537. https://psnet.ahrq.gov/issue/factors-influencing-provider…

6197. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45506/psn-pdf
      November 30, 2016 - Is an indication-based prescribing system in our future? November 30, 2016 ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5. https://psnet.ahrq.gov/issue/indication-based-prescribing-system-our-future Health information technology has enhanced prescribers' ability to document the purpose o…

6198. Overview | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/enhanced-recovery/overview.html
      June 01, 2023 - Overview Tools and Resources To Help Hospitals Choose an ISCR Program This section gives a high-level overview of the Improving Surgical Care and Recovery (ISCR) program to support hospitals in implementing evidence-based enhanced recovery pathways. The Overview lists the tools and materials, organized in the…

6199. Synthesizing the Outputs of Deliberative Forum (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/delilberative-methods-design-abelson-2.pdf
      May 29, 2025 - Synthesizing the Outputs of Deliberative Forum Synthesizing the Outputs of Deliberative Forum Julia Abelson, PhD Department of Clinical Epidemiology & Biostatistics McMaster University Hamilton, Ontario CANADA Slide 27 Linking deliberation objectives to outputs  What is the expected deliverable of th…

6200. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47615/psn-pdf
      January 30, 2019 - A Crisis in Health Care: A Call to Action on Physician Burnout. January 30, 2019 Jha AK, Iliff AR, Chaoui AA, et al. Waltham, MA: Massachusetts Medical Society, Massachusetts Health and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute; 2019. https://psnet.ahrq.g…