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psnet.ahrq.gov/issue/iv-potassium-given-epidurally-getting-route-problem
April 20, 2022 - Newspaper/Magazine Article
IV potassium given epidurally: getting to the "route" of the problem.
Citation Text:
IV potassium given epidurally: getting to the "route" of the problem. ISMP Medication Safety Alert! Acute care edition. April 6, 2006.
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND_0367_11-08-2010.pdf
January 01, 2010 - Effective Health Care
Topic Number: 0309
Document Completion Date: 03-22-11
1
Results of Topic Selection Process & Next Steps
Efficacy and safety of screening and treatment of postpartum depression will go forward for refinement
as a systematic review. The scope of this topic, including popula…
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psnet.ahrq.gov/issue/foundations-safety-science
August 07, 2019 - Special or Theme Issue
The Foundations of Safety Science.
Citation Text:
The Foundations of Safety Science. LeCoze JC, Pettersen K, Reiman T, eds. Safety Sci. 2014;67:1-70.
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psnet.ahrq.gov/issue/sentinel-event-alert
May 30, 2012 - Newsletter/Journal
Sentinel Event Alert.
Citation Text:
Sentinel Event Alert. Oakbrook Terrace, IL: The Joint Commission.
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psnet.ahrq.gov/issue/how-guides-improving-transitions-hospital-reduce-avoidable-rehospitalizations
November 18, 2011 - Special or Theme Issue
How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations.
Citation Text:
How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; Jun…
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psnet.ahrq.gov/issue/coding-success-simple-technology-safer-patient-care
July 01, 2020 - Book/Report
Coding for Success: Simple Technology for Safer Patient Care.
Citation Text:
Coding for Success: Simple Technology for Safer Patient Care. Healthcare Quality Directorate, Department of Health. London, UK; Crown Copyright: 2007.
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psnet.ahrq.gov/issue/habits-improver-thinking-about-learning-improvement-health-care
November 25, 2015 - Book/Report
The Habits of an Improver. Thinking About Learning for Improvement in Health Care.
Citation Text:
The Habits of an Improver. Thinking About Learning for Improvement in Health Care. Lucas B, Nacer H. London, UK: Health Foundation; October 2015. ISBN: 9781906461676.
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psnet.ahrq.gov/issue/fluorouracil-incident-root-cause-analysis-report
September 02, 2014 - Book/Report
Fluorouracil Incident Root Cause Analysis Report.
Citation Text:
Fluorouracil Incident Root Cause Analysis Report. Toronto, CA: Institute for Safe Medication Practices Canada; May 2007.
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psnet.ahrq.gov/issue/safe-intrahospital-transport-non-icu-patient-using-standardized-handoff-communication
March 18, 2010 - Newspaper/Magazine Article
Safe intrahospital transport of the non-ICU patient using standardized handoff communication.
Citation Text:
Safe intrahospital transport of the non-ICU patient using standardized handoff communication. PA-PSRS Patient Safety Advisory; Patient Safety Authority.…
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psnet.ahrq.gov/issue/ashp-statement-bar-code-verification-during-inventory-preparation-and-dispensing-medications
June 17, 2014 - Organizational Policy/Guidelines
ASHP statement on bar-code verification during inventory, preparation, and dispensing of medications.
Citation Text:
ASHP statement on bar-code verification during inventory, preparation, and dispensing of medications. Am J Health-Syst Pharm. 2011;68:44…
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psnet.ahrq.gov/issue/accidental-overdoses-involving-fluorouracil-infusions
July 08, 2015 - Newspaper/Magazine Article
Accidental overdoses involving fluorouracil infusions.
Citation Text:
Accidental overdoses involving fluorouracil infusions. ISMP Medication Safety Alert! Acute Care Edition. June 18, 2015;20:1:5.
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hcup-us.ahrq.gov/datainnovations/clinicaldata/FL26LOINCMappingEvaluation.pdf
September 22, 2010 - Evaluation of LOINC Mapping Process Report
CHARLIE CRIST
GOVERNOR Better Health Care for all Floridians HOLLY BENSON
SECRETARY
[Hospital or System Name] ’s Evaluation of LOINC Mapping Process
Report
Hospital Description
1. General description of the types of hospitals that are in your syst…
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psnet.ahrq.gov/issue/limiting-resident-physicians-work-hours-save-lives
May 04, 2011 - Newspaper/Magazine Article
Limiting resident physicians' work hours to save lives.
Citation Text:
Limiting resident physicians' work hours to save lives. Leape L, Haskell H. Los Angeles Times. July 1, 2011.
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psnet.ahrq.gov/issue/world-patient-safety-day
September 30, 2020 - Multi-use Website
World Patient Safety Day.
Citation Text:
World Patient Safety Day. World Health Organization. September 17, 2025.
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psnet.ahrq.gov/issue/listening-what-matters-avoiding-contextual-errors-health-care
February 03, 2016 - Book/Report
Listening for What Matters: Avoiding Contextual Errors in Health Care.
Citation Text:
Listening for What Matters: Avoiding Contextual Errors in Health Care. Weiner SJ, Schwartz A. New York, NY: Oxford University Press; 2016. ISBN: 9780190228996.
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integrationacademy.ahrq.gov/news-and-events/news/substance-misuse-through-lens-black-history-month
February 21, 2024 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
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Integrating Behavioral Health & Primary Care
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psnet.ahrq.gov/issue/patient-safety-huddle
March 27, 2005 - Audiovisual
Patient Safety Huddle.
Citation Text:
Patient Safety Huddle. VA National Center for Patient Safety.
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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.