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  1. effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-high-risk-drugs-rapid-response.pdf
    January 01, 2024 - of anticoagulation in the ambulatory setting improved time in therapeutic range, and telepharmacy reduced … telemedicine and self-testing statistically significantly improved TTR compared to usual care; while it also reduced … number of patients enrolled per pharmacy, or the number of pharmacies providing the service, which reduced … therapeutic range (MD 9.50%; 95% CI, 3.16–15.85; I2 = 87%; P< 0.01) • The combined intervention reduced
  2. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-removal-notes.docx
    April 01, 2022 - Central Venous Catheter Removal Facilitator Notes CLABSI Module: Central Venous Catheter Removal Facilitator Guide Slide Number and Image This module, titled Central Venous Catheter Removal, is part of the Agency for Healthcare Research and Quality’s Safety Program for intensive care units (ICUs). The module ad…
  3. effectivehealthcare.ahrq.gov/sites/default/files/interventions-horizon-scan-high-impact-1306.pdf
    June 01, 2013 - Experts expected to see the program’s most dramatic effects in reduced health care costs, improved … thought that physicians would likely appreciate the support to care for patients in their homes and the reduced … could be recouped over time as inappropriate ED visits and hospitalizations and readmissions are reduced … They noted the potential for improved patient outcomes and the reduced number of hospital admissions
  4. datatools.ahrq.gov/nhqdr/resources-addressing-disparities-and-improving-quality/
    January 01, 2022 - Skip to main content An official website of the Department of Health and Human Services Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates Data Tools Home CAHPS HCUP …
  5. psnet.ahrq.gov/innovations
    February 26, 2025 - Innovations The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
  6. digital.ahrq.gov/principal-investigator/koppel-ross
    January 01, 2023 - Koppel, Ross Guide to reducing unintended consequences of electronic health records. Citation Jones SS, Koppel R, Ridgely MS, et al. Guide to reducing unintended consequences of electronic health records. (Prepared by RAND Corporation under Contract No. 290-06-0017-5). AHRQ Pu…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845652/psn-pdf
    March 14, 2023 - Controlled substance drug diversion by healthcare workers as a threat to patient safety. March 14, 2023 ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4. https://psnet.ahrq.gov/issue/controlled-substance-drug-diversion-healthcare-workers-threat-patient-safety D…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47148/psn-pdf
    June 25, 2018 - Necessity for a pathway for "high-alert" patients. June 25, 2018 Shane R, Amer K, Noh L, et al. Necessity for a pathway for "high-alert" patients. Am J Health Syst Pharm. 2018;75(13):993-997. doi:10.2146/ajhp170397. https://psnet.ahrq.gov/issue/necessity-pathway-high-alert-patients Medication errors can contribute…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838081/psn-pdf
    September 14, 2022 - Medication dosage calculation among nursing students: does digital technology make a difference? A literature review. September 14, 2022 Stake-Nilsson K, Almstedt M, Fransson G, et al. Medication dosage calculation among nursing students: does digital technology make a difference? A literature review. BMC Nurs. 20…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45650/psn-pdf
    December 14, 2016 - Are physicians safely prescribing opioids for chronic noncancer pain? A systematic review of current evidence. December 14, 2016 Tournebize J, Gibaja V, Muszczak A, et al. Are Physicians Safely Prescribing Opioids for Chronic Noncancer Pain? A Systematic Review of Current Evidence. Pain Pract. 2016;16(3):370-83. d…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73566/psn-pdf
    August 04, 2021 - Personal formularies of primary care physicians across 4 health care systems. August 4, 2021 Galanter W, Eguale T, Gellad WF, et al. Personal formularies of primary care physicians across 4 health care systems. JAMA Netw Open. 2021;4(7):e2117038. doi:10.1001/jamanetworkopen.2021.17038. https://psnet.ahrq.gov/issue…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47783/psn-pdf
    April 10, 2019 - An IDEA: safety training to improve critical thinking by individuals and teams. April 10, 2019 Browne AM, Deutsch ES, Corwin K, et al. An IDEA: Safety Training to Improve Critical Thinking by Individuals and Teams. Am J Med Qual. 2019;34(6):569-576. doi:10.1177/1062860618820687. https://psnet.ahrq.gov/issue/idea-s…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47542/psn-pdf
    January 16, 2019 - Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care. January 16, 2019 Kreitzer MJ, Carter K, Coffey DS, et al. NAM Perspectives. Washington, DC: National Academy of Medicine; 2019. https://psnet.ahrq.gov/issue/utilizing-systems-and-design-…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837073/psn-pdf
    May 11, 2022 - Clinical progress note: situation awareness for clinical deterioration in hospitalized children. May 11, 2022 Sosa T, Galligan MM, Brady PW. Clinical progress note: situation awareness for clinical deterioration in hospitalized children. J Hosp Med. 2022;17(3):199-202. doi:10.1002/jhm.2774. https://psnet.ahrq.gov/…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73530/psn-pdf
    July 28, 2021 - The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: the QUMwatch study. July 28, 2021 Adie K, Fois RA, McLachlan AJ, et al. The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: T…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46088/psn-pdf
    May 24, 2017 - Innovative use of the electronic health record to support harm reduction efforts. May 24, 2017 Hyman D, Neiman J, Rannie M, et al. Innovative Use of the Electronic Health Record to Support Harm Reduction Efforts. Pediatrics. 2017;139(5). doi:10.1542/peds.2015-3410. https://psnet.ahrq.gov/issue/innovative-use-elect…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47495/psn-pdf
    October 31, 2018 - Developing and evaluating clinical leadership interventions for frontline healthcare providers: a review of the literature. October 31, 2018 Mianda S, Voce A. Developing and evaluating clinical leadership interventions for frontline healthcare providers: a review of the literature. BMC Health Serv Res. 2018;18(1):…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47224/psn-pdf
    June 27, 2018 - Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry. June 27, 2018 Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry. Crit Care Nurse. 2018;38(2):e16-e20. doi:10.4037/ccn2018468. https://psnet.ahrq.gov/issue/managing-alarms-acute-care-…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36698/psn-pdf
    February 24, 2011 - The impact of duty hours on resident self reports of errors. February 24, 2011 Vidyarthi A, Auerbach AD, Wachter R, et al. The impact of duty hours on resident self reports of errors. J Gen Intern Med. 2007;22(2):205-9. https://psnet.ahrq.gov/issue/impact-duty-hours-resident-self-reports-errors Residency programs…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866270/psn-pdf
    July 10, 2024 - Identifying and measuring administrative harms experienced by hospitalists and administrative leaders. July 10, 2024 Burden M, Astik GJ, Auerbach AD, et al. Identifying and measuring administrative harms experienced by hospitalists and administrative leaders. JAMA Intern Med. 2024;184(9):1014-1023. doi:10.1001/jam…