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psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - case demonstrates a multitude of nighttime systems vulnerabilities, including inadequate handoffs, reduced
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www.ahrq.gov/prevention/resources/depression/depsum1.html
April 01, 2013 - Meta-analysis suggests that overall, screening and feedback reduced the risk for persistent depression
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psnet.ahrq.gov/curated-library/diagnostic-error
September 14, 2025 - how uncertainty drives reasoning, test overuse, and physician discomfort to culminate in waste and reduced
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module6/facilitator-notes.docx
March 01, 2017 - Lack of Organizational Infrastructure and Resources
Programs are often discontinued when resources are reduced
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www.ahrq.gov/news/events/nac/2020-03-nac/nacmtg032620-minutes.html
August 01, 2020 - Program (CUSP) was used in a safety implementation program for improving antibiotic use and resulted in reduced
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digital.ahrq.gov/sites/default/files/docs/citation/r21hs028119-hartung-final-report-2024.pdf
January 01, 2024 - integration increased the likelihood of
reviewing PDMP profiles and 75% indicated that integration reduced
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psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - With the decrease in plasma glucose levels, insulin secretion by the pancreas is reduced, which then
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psnet.ahrq.gov/web-mm/silent-pain-neck
August 19, 2020 - endarterectomy (CEA), and thyroidectomy are becoming increasingly routine procedures, and many centers have reduced
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - While complications cannot be entirely eliminated, their incidence can be reduced by careful patient
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/migraine-future_research.pdf
April 01, 2013 - achieving complete cessation of migraine, improvement in Headache Index scores by 50 percent
or more, and reduced … It reduced pain measured with SF-36, but did not decrease use of drugs for
acute migraine attacks. … It reduced pain measured with SF-36 but did not decrease use of drugs for acute
migraine attacks.
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psnet.ahrq.gov/web-mm/need-eat
February 10, 2021 - that if the stomach is empty, then the potential for aspiration of stomach contents during sedation is reduced
-
www.ahrq.gov/sites/default/files/2024-11/becker-bix-report.pdf
January 01, 2024 - medications deemed appropriate by the pharmacists also found
that the presence of a front-of-pack warning reduced … producing a better ability to
differentiate appropriate from inappropriate drugs; the same pattern of reduced
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-222-evidence-summary-health-equity.pdf
January 01, 2020 - Rates
of high blood pressure were not reduced with
an intervention involving lay health workers,
education
-
psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - Opioid Overdose as a Patient Safety Problem
May 22, 2017
Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
Perspective
Opioids serve a valuable role in the treatment of acute pain and pain associat…
-
psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - Learning Health Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
Despite an observable decrease in adverse events in health care over time, rat…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.60_slideshow.ppt
May 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case May 2004
Too Tight Control:
The Risks of Intensive Insulin Therapy
Source and Credits
This presentation is based on the May 2004
AHRQ WebM&M Spotlight Case in Medicine
CME credit is available through the Web site
See the full article at http://webmm.ahrq.gov
Comm…
-
psnet.ahrq.gov/node/49826/psn-pdf
April 01, 2018 - Air on the Side of Caution
April 1, 2018
Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/air-side-caution
The Case
A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of
breath and chest pain. A decision was m…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-ve-supp-item-set-08-2022.pdf
January 01, 2022 - SOPS® Value and Efficiency Supplemental Items for the SOPS Hospital Survey - English
SOPS® Value and Efficiency Supplemental
Item Set for the SOPS Hospital Survey
Language: English
• Purpose: This supplemental item set was designed for use with the core SOPS® Hospital Survey Version 2.0
to help hospitals assess…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-insertion.pptx
April 01, 2022 - Central Venous Catheter Insertion
Central Venous Catheter Insertion
Avoiding Improper Placement Techniques
AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI
AHRQ Pub. No. 17(22)-0019
April 2022
AHRQ Safety Program for Intensive Care Units: CLABSI/CAUTI
1
Disrupting the Lifecycle of a Cathet…