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psnet.ahrq.gov/issue/alert-reports-severe-harm-after-intravenous-administration-breast-milk-infants
May 02, 2018 - Newspaper/Magazine Article
ALERT: reports of severe harm after intravenous administration of breast milk to infants.
Citation Text:
ALERT: reports of severe harm after intravenous administration of breast milk to infants. ISMP Canada Safety Bulletin. July 31, 2011;11:1-2.
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psnet.ahrq.gov/issue/10-medication-safety-tips-hospitalized-patients
February 06, 2019 - Fact Sheet/FAQs
10 Medication Safety Tips for Hospitalized Patients.
Citation Text:
10 Medication Safety Tips for Hospitalized Patients. Horsham, PA: Institute for Safe Medication Practices; 2019.
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psnet.ahrq.gov/issue/ismp-list-high-alert-medications-communityambulatory-healthcare
December 15, 2021 - Fact Sheet/FAQs
ISMP List of High-Alert Medications in Community/Ambulatory Healthcare.
Citation Text:
ISMP List of High-Alert Medications in Community/Ambulatory Healthcare. Horsham, PA: Institute for Safe Medication Practices; 2021.
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psnet.ahrq.gov/issue/canadian-disclosure-guidelines-being-open-and-honest-patients-and-families
September 08, 2010 - Book/Report
Canadian Disclosure Guidelines: Being Open and Honest with Patients and Families.
Citation Text:
Canadian Disclosure Guidelines: Being Open and Honest with Patients and Families. Disclosure Working Group. Edmonton, AB, Canada; Canadian Patient Safety Institute; 2011. ISBN 978…
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psnet.ahrq.gov/issue/misprogramming-pca-concentration-leads-dosing-errors
May 02, 2018 - Newspaper/Magazine Article
Misprogramming PCA concentration leads to dosing errors.
Citation Text:
Misprogramming PCA concentration leads to dosing errors. ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.
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psnet.ahrq.gov/issue/benefits-and-risks-including-patients-rca-teams
May 02, 2018 - Newspaper/Magazine Article
Benefits and risks of including patients on RCA teams.
Citation Text:
Benefits and risks of including patients on RCA teams. ISMP Medication Safety Alert! Acute Care Edition. June 5, 2008;13:1-3.
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psnet.ahrq.gov/issue/oral-medications-inadvertently-given-intravenous-route
December 19, 2016 - Government Resource
Oral medications inadvertently given via the intravenous route.
Citation Text:
Oral medications inadvertently given via the intravenous route. Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
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psnet.ahrq.gov/issue/advancing-safety-closed-loop-communication-test-results
November 13, 2019 - Newspaper/Magazine Article
Advancing safety with closed-loop communication of test results.
Citation Text:
Advancing safety with closed-loop communication of test results. Quick Safety. December 17, 2019;(52):1-3.
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psnet.ahrq.gov/issue/conversation-patient-safety-officers
April 30, 2024 - Book/Report
A Conversation with Patient Safety Officers.
Citation Text:
A Conversation with Patient Safety Officers. Harrisburg, PA: Patient Safety Authority; 2007.
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digital.ahrq.gov/ahrq-funded-projects/electronic-health-record-information-design-and-usability-toolkit
January 01, 2023 - Electronic Health Record Information Design and Usability Toolkit
Project Final Report ( PDF , 1.03 MB)
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Disclaimer details
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Project Description
Annual Summaries
Publications
Project Details -
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psnet.ahrq.gov/issue/partnering-patients-and-families-enhance-safety-and-quality-mini-toolkit
September 12, 2018 - Toolkit
Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit.
Citation Text:
Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit. Bethesda, MD: Institute for Patient- and Family-Centered Care; 2011.
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psnet.ahrq.gov/issue/toward-improving-outcome-pregnancy-enhancing-perinatal-health-through-quality-safety-and
June 24, 2015 - Book/Report
Toward Improving the Outcome of Pregnancy: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives (TIOP III).
Citation Text:
Toward Improving the Outcome of Pregnancy: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives (T…
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psnet.ahrq.gov/issue/pain-wrong-site-surgery
November 28, 2016 - Newspaper/Magazine Article
The pain of wrong site surgery.
Citation Text:
The pain of wrong site surgery. Boodman SG. Washington Post. June 21, 2011:E1.
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psnet.ahrq.gov/issue/shining-glaring-light-surgery-technology-records-every-move-aims-improve-safety
January 29, 2020 - Newspaper/Magazine Article
Shining a glaring light on surgery: technology that records every move aims to improve safety.
Citation Text:
Shining a glaring light on surgery: technology that records every move aims to improve safety. Freyer FJ. Boston Globe. January 13, 2024.
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www.ahrq.gov/news/newsroom/case-studies/201530.html
November 01, 2015 - Research Medical Center Develops Video to Encourage Continued Use of TeamSTEPPS®
Search All Impact Case Studies
November 2015
The Graduate Nurse Residency Program at Research Medical Center in Kansas City, Missouri, created a video highlighting nine concepts of AHRQ's TeamSTEPPS® program as a way to re-…
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psnet.ahrq.gov/issue/burnout-crisis-american-medicine
September 03, 2014 - Newspaper/Magazine Article
The burnout crisis in American medicine.
Citation Text:
The burnout crisis in American medicine. Xu R. The Atlantic. May 11, 2018.
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psnet.ahrq.gov/issue/pearls-pitfalls-and-errors-musculoskeletal-diagnosis
February 26, 2025 - Special or Theme Issue
Pearls, Pitfalls, and Errors in Musculoskeletal Diagnosis.
Citation Text:
Pearls, Pitfalls, and Errors in Musculoskeletal Diagnosis. Blankenbaker DG, ed. AJR Am J Roentgenol. 2014;203(3):476-593.
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs022586-lacson-final-report-2017.pdf
January 01, 2017 - follow-up
recommendations to ambulatory primary care physicians (PCP) on timely implementation of
recommended … documented communication of critical results between
caregivers, a deficit remained in adherence to recommended … Specific Aim 2: Evaluate the impact of the system on timely implementation of recommended
follow-up … an explicit radiologist recommendation was a significant predictor
(p<0.05) for completion of the recommended … A secondary outcome is
the rate of completion of the recommended follow-up exam.
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cds.ahrq.gov/sites/default/files/cds/artifact/396/cap_3_DecidExecut.html
January 01, 1970 - recommendation; Reason: Logic: Conditional: Direct admission to an ICU or high-level monitoring unit is recommended … Cost: Recommendation Recommended diagnostic tests for etiology.
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cds.ahrq.gov/sites/default/files/cds/artifact/711/Anthrax_Post_Exposure_Prophylaxis_CDS_Validation_Report.pdf
October 17, 2018 - Logic encoded into the CDS determines the patient-
specific recommended treatment and can also provide … Either there is an indication that the recommended dosing
sequence was not followed (i.e., there is … OrderSet PlanDefinition
(STU3)
The order set containing the recommended treatment for
Anthrax PEP … It references the ActionList and the
ContainedResourcesList, which contain the recommended
treatments … If treatment is not recommended, then
this resource will be empty.