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psnet.ahrq.gov/issue/early-experience-peer-advocate-program-using-quality-improvement-optimize-behavioral-and
September 23, 2020 - Study
Early experience of peer advocate program: using quality improvement to optimize behavioral and communication disconnect in the operating room.
Citation Text:
Eckhouse SR, Huston M, Smith ER, et al. Early experience of peer advocate program: using quality improvement to optimize be…
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psnet.ahrq.gov/issue/effectiveness-interruptive-prescribing-alerts-ambulatory-cpoe-change-prescriber-behaviour-and
February 02, 2022 - Review
The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour and improve safety.
Citation Text:
Cerqueira O, Gill M, Swar B, et al. The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour and …
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www.ahrq.gov/news/blog/ahrqviews/world-patient-safety-day-2024.html
September 01, 2024 - AHRQ Views: Blog posts from AHRQ leaders
On World Patient Safety Day, AHRQ Highlights the Urgent Need to Address Diagnostic Safety
SEP
16
2024
By
Robert Otto Valdez, Ph.D., M.H.S.A., and
Craig A. Umscheid, M.D., M.S.
Robert Otto Valdez, Ph.D., M.H.S.
As the healthcar…
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digital.ahrq.gov/type-care/primary-care
January 01, 2023 - Primary Care
Complexity, Incidence, and Costs Related to Delayed Diagnosis of Venous Thromboembolism in Urban and Rural Primary and Urgent Care Settings
Description
This research aims to improve the early detection of venous thromboembolism in primary and urgent care by using …
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psnet.ahrq.gov/issue/situ-simulation-quality-improvement-tool-identify-and-mitigate-latent-safety-threats
February 22, 2023 - Study
In situ simulation as a quality improvement tool to identify and mitigate latent safety threats for emergency department SARS-CoV-2 airway management: a multi-institutional initiative.
Citation Text:
Yang CJ, Saggar V, Seneviratne N, et al. In situ simulation as a quality improveme…
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psnet.ahrq.gov/issue/governing-patient-safety-lessons-learned-mixed-methods-evaluation-implementing-ward-level
June 25, 2014 - Study
Governing patient safety: lessons learned from a mixed methods evaluation of implementing a ward-level medication safety scorecard in two English NHS hospitals.
Citation Text:
Ramsay AIG, Turner S, Cavell G, et al. Governing patient safety: lessons learned from a mixed methods ev…
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psnet.ahrq.gov/issue/developing-process-measure-actual-harm-medication-errors-paediatric-inpatients-design
January 18, 2023 - Study
Developing a process to measure actual harm from medication errors in paediatric inpatients: from design to implementation.
Citation Text:
Mumford V, Raban MZ, Li L, et al. Developing a process to measure actual harm from medication errors in paediatric inpatients: from design to i…
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psnet.ahrq.gov/issue/why-learning-patient-safety-incidents-still-so-hard-sociocultural-perspective-learning
June 29, 2011 - Study
Why is learning from patient safety incidents (still) so hard? A sociocultural perspective on learning from incidents in healthcare organizations.
Citation Text:
Rowland P, Lan MF, Wan C, et al. Why is learning from patient safety incidents (still) so hard? A sociocultural perspect…
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psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-solved
September 24, 2014 - Study
Retained surgical items: a problem yet to be solved.
Citation Text:
Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, et al. Retained surgical items: a problem yet to be solved. J Am Coll Surg. 2013;216(1):15-22. doi:10.1016/j.jamcollsurg.2012.08.026.
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psnet.ahrq.gov/issue/medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults
March 05, 2008 - Study
Classic
Medication use leading to emergency department visits for adverse drug events in older adults.
Citation Text:
Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for adverse drug events in older adults. A…
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psnet.ahrq.gov/issue/medication-opioid-use-disorder-after-nonfatal-opioid-overdose-and-association-mortality
October 03, 2018 - Study
Classic
Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study.
Citation Text:
Larochelle MR, Bernson D, Land T, et al. Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Associat…
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psnet.ahrq.gov/issue/interprofessional-clinical-event-debriefing-does-it-make-difference-attitudes-emergency
April 06, 2022 - Study
Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings.
Citation Text:
Rose SC, Ashari NA, Davies JM, et al. Interprofessional clinical event debriefing-does it make a difference? At…
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psnet.ahrq.gov/issue/impact-agency-healthcare-research-and-qualitys-safety-program-perinatal-care
April 04, 2018 - Study
Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.
Citation Text:
Kahwati LC, Sorensen A, Teixeira-Poit S, et al. Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care. Jt Comm J Qual Patient Saf. 201…
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psnet.ahrq.gov/issue/identifying-medication-errors-neonatal-intensive-care-units-two-center-study
November 11, 2020 - Study
Identifying medication errors in neonatal intensive care units: a two-center study
Citation Text:
Eslami K, Aletayeb F, Aletayeb SMH, et al. Identifying medication errors in neonatal intensive care units: a two-center study. BMC Pediatr. 2019;19(1):365. doi:10.1186/s12887-019-1748-…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-tubes.pdf
June 02, 2025 - NICU Family Information Packet, Appendix B, Feeding Tubes
Feeding Tubes
Types of Devices
■ Nasogastric (NG) tube: non-weighted, polyurethane tube for use more than 10 days.
■ Gastrostomy tube: tube protrudes from anterior abdominal wall; most common initial
gastrostomy device.
■ Button/skin-level gastrostomy: …
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psnet.ahrq.gov/issue/clinical-and-economic-outcomes-attributable-health-care-associated-sepsis-and-pneumonia
December 09, 2015 - Study
Clinical and economic outcomes attributable to health care–associated sepsis and pneumonia.
Citation Text:
Eber MR, Laxminarayan R, Perencevich E, et al. Clinical and economic outcomes attributable to health care-associated sepsis and pneumonia. Arch Intern Med. 2010;170(4):347-53.…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-k.pdf
June 02, 2025 - Appendix K. Infographic Poster on CAUTI Prevention
AHRQ Safety Program for Reducing CAUTI in Hospitals
Appendix K. Infographic Poster on CAUTI Prevention
The poster on the following page is intended to be printed with dimensions of 28 by 36 inches.
This can be done by sending the PDF out to a printer for large-f…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-targeted-decolonization.pdf
March 01, 2022 - Addressing Questions Asked by Staff: Targeted Decolonization
Decolonization of
Non-ICU Patients With Devices
Section 14-4 – Addressing Questions Asked by Staff:
Targeted Decolonization
What is targeted decolonization?
Participating non-ICU units at your hospital will be decolonizing adult patients with …
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psnet.ahrq.gov/issue/current-teaching-and-evaluation-methods-critical-care-medicine-has-accreditation-council
February 23, 2022 - Study
Current teaching and evaluation methods in critical care medicine: has the Accreditation Council for Graduate Medical Education affected how we practice and teach in the intensive care unit?
Citation Text:
Chudgar SM, Cox CE, Que LG, et al. Current teaching and evaluation methods…
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psnet.ahrq.gov/issue/combining-multiple-large-language-models-improves-diagnostic-accuracy
March 02, 2011 - Study
Combining multiple large language models improves diagnostic accuracy.
Citation Text:
Barabucci G, Shia V, Chu ES, et al. Combining multiple large language models improves diagnostic accuracy. NEJM AI. 2024;1(11):AIcs2400502. doi:10.1056/aics2400502.
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