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psnet.ahrq.gov/issue/embracing-errors-simulation-based-training-effect-error-training-retention-and-transfer
May 23, 2013 - Study
Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills.
Citation Text:
Gardner AK, Abdelfattah K, Wiersch J, et al. Embracing Errors in Simulation-Based Training: The Effect of Error Training on Retent…
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psnet.ahrq.gov/issue/quality-improvement-initiative-using-peer-audit-and-feedback-improve-compliance-surgical
March 24, 2021 - Study
A quality improvement initiative using peer audit and feedback to improve compliance with the surgical safety checklist.
Citation Text:
Fridrich A, Imhof A, Staender S, et al. A quality improvement initiative using peer audit and feedback to improve compliance. Int J Qual Health C…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-wound-cleaning.pdf
March 01, 2022 - Addressing Questions Asked by Staff: Wound Cleaning
Decolonization of
Non-ICU Patients With Devices
Section 14-5 – Addressing Questions Asked by Staff:
Wound Cleaning
There are some new nurses and nursing assistants on our unit. How can I ease
any concerns related to wound cleaning?
Some nurses and n…
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psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patient-safety
February 14, 2024 - Commentary
Classic
Errors in laboratory medicine: practical lessons to improve patient safety.
Citation Text:
Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab Med. 2005;129(10):1252-1261.
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psnet.ahrq.gov/issue/responses-physicians-objective-safety-and-quality-knowledge-test-cross-sectional-study
March 24, 2021 - Study
Responses of physicians to an objective safety and quality knowledge test: a cross-sectional study.
Citation Text:
Burke HB, King HB. Responses of physicians to an objective safety and quality knowledge test: a cross-sectional study. BMJ Open. 2021;11(9):e040779. doi:10.1136/bmjope…
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www.ahrq.gov/ncepcr/reports/2025-annual-report/public-health.html
August 01, 2025 - AHRQ’s Investments in Primary Care Research for 2023 and 2024
Public Health and Community Integration
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Table of Contents
AHRQ’s Investments in Primary Care Research for 2023 and 2024
Acknowledgements and Authors
Message from the Director of AHRQ’s National Center for Exc…
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psnet.ahrq.gov/issue/hospital-admissions-associated-medication-non-adherence-systematic-review-prospective
August 28, 2013 - Review
Emerging Classic
Hospital admissions associated with medication non-adherence: a systematic review of prospective observational studies.
Citation Text:
Mongkhon P, Ashcroft DM, Scholfield N, et al. Hospital admissions associated with medication non-adhere…
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psnet.ahrq.gov/issue/association-between-physician-depressive-symptoms-and-medical-errors-systematic-review-and
January 12, 2022 - Review
Emerging Classic
Association between physician depressive symptoms and medical errors: A systematic review and meta-analysis
Citation Text:
Pereira-Lima K, Mata DA, Loureiro SR, et al. Association Between Physician Depressive Symptoms and Medical Errors: …
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-preventablereadm-primcare-es.pdf
March 01, 2020 - Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care: Executive Summary
Potentially Preventable Readmissions:
Conceptual Framework To Rethink the Role of
Primary Care
Executive Summary
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of H…
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www.ahrq.gov/hai/cusp/clabsi-hpwpreport/clabsi-hpwp2.html
August 01, 2015 - High-Performance Work Practices in CLABSI Prevention Interventions
Case Studies
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Table of Contents
High-Performance Work Practices in CLABSI Prevention Interventions
Case Studies
Key Findings
Conclusions
References
Table 1. Case Study Sites
Table 2. Summary of Ke…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-rural-healthcare2.html
October 01, 2024 - Diagnostic Excellence in U.S. Rural Healthcare: A Call to Action
Improving Diagnosis in the Context of Rurality
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Table of Contents
Diagnostic Excellence in U.S. Rural Healthcare: A Call to Action
A Path to Rural Diagnostic Excellence
Improving Diagnosis in the Context of R…
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psnet.ahrq.gov/issue/initiatives-identify-and-mitigate-medication-errors-england
July 22, 2020 - Commentary
Initiatives to identify and mitigate medication errors in England.
Citation Text:
Cousins D, Gerrett D, Richards N, et al. Initiatives to identify and mitigate medication errors in England. Drug Saf. 2015;38(4):349-357. doi:10.1007/s40264-015-0270-3.
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psnet.ahrq.gov/issue/tying-loose-ends-discharging-patients-unresolved-medical-issues
February 24, 2011 - Study
Tying up loose ends: discharging patients with unresolved medical issues.
Citation Text:
Moore C, McGinn T, Halm E. Tying up loose ends: discharging patients with unresolved medical issues. Arch Intern Med. 2007;167(12):1305-11.
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Format:
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psnet.ahrq.gov/issue/safer-prescribing-and-care-elderly-space-cluster-randomised-controlled-trial-general-practice
November 18, 2020 - Study
Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice.
Citation Text:
Wallis KA, Elley CR, Moyes SA, et al. Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice. BJGP Open. …
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psnet.ahrq.gov/issue/stoppstart-criteria-potentially-inappropriate-prescribing-older-people-version-2
March 23, 2012 - Study
STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.
Citation Text:
O'Mahony D, O'Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213-218. doi:10.1093…
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www.ahrq.gov/news/newsroom/case-studies/cquips0802.html
October 01, 2014 - AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors in Emergency Departments
Search All Impact Case Studies
June 2008
AHRQ-sponsored research on how clinical pharmacy services can reduce medication-related errors in hospital emergency departments has been put to use in hospitals in a …
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digital.ahrq.gov/ahrq-funded-projects/rural-community-partnerships-electronic-medical-record-emr-implementation
January 01, 2023 - Rural Community Partnerships - Electronic Medical Record (EMR) Implementation Project
Project Final Report ( PDF , 165.13 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessar…
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psnet.ahrq.gov/issue/6-pack-programme-decrease-fall-injuries-acute-hospitals-cluster-randomised-controlled-trial
December 21, 2014 - Study
Classic
6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial.
Citation Text:
Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled t…
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psnet.ahrq.gov/issue/patient-safety-resident-education-and-resident-well-being-following-implementation-2003-acgme
June 20, 2012 - Review
Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules.
Citation Text:
Fletcher KE, Reed DA, Arora V. Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rule…
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psnet.ahrq.gov/issue/specialty-based-voluntary-incident-reporting-neonatal-intensive-care-description-4846
March 09, 2010 - Study
Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports.
Citation Text:
Snijders C, van Lingen RA, Klip H, et al. Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports.…