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psnet.ahrq.gov/node/40903/psn-pdf
March 08, 2015 - Does your patient really understand?
March 8, 2015
Huff C. Does your patient really understand? Hospitals & health networks. 2011;85(10):34-5, 37-8, 2.
https://psnet.ahrq.gov/issue/does-your-patient-really-understand
This article discusses health literacy and describes an initiative to reduce gaps in understanding …
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psnet.ahrq.gov/node/41955/psn-pdf
January 09, 2013 - Making Medical Devices Safer at Home.
January 9, 2013
Consumer Updates. Silver Spring, MD: US Food and Drug Administration; December 12, 2012.
https://psnet.ahrq.gov/issue/making-medical-devices-safer-home
Highlighting concerns associated with patients' use of medical devices at home, such as difficulty
understand…
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psnet.ahrq.gov/node/42830/psn-pdf
December 18, 2013 - How to Identify and Address Unsafe Conditions
Associated With Health IT.
December 18, 2013
Wallace C, Zimmer KP, Possanza L, Giannini R, Solomon R. Washington, DC: Office of the National
Coordinator for Health Information Technology; November 15, 2013.
https://psnet.ahrq.gov/issue/how-identify-and-address-unsafe-c…
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psnet.ahrq.gov/node/40668/psn-pdf
March 04, 2015 - Body CT: technical advances for improving safety.
March 4, 2015
Marin D, Nelson RC, Rubin GD, et al. Body CT: technical advances for improving safety. AJR Am J
Roentgenol. 2011;197(1):33-41. doi:10.2214/AJR.11.6755.
https://psnet.ahrq.gov/issue/body-ct-technical-advances-improving-safety
This article explores risk…
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psnet.ahrq.gov/node/42364/psn-pdf
September 18, 2013 - The pursuit of better diagnostic performance: a human
factors perspective.
September 18, 2013
Henriksen K, Brady J. The pursuit of better diagnostic performance: a human factors perspective. BMJ
Qual Saf. 2013;22(Suppl 2):ii1-ii5. doi:10.1136/bmjqs-2013-001827.
https://psnet.ahrq.gov/issue/pursuit-better-diagnosti…
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psnet.ahrq.gov/node/38341/psn-pdf
April 02, 2009 - CPOE: it don't come easy.
April 2, 2009
Anderson HJ. CPOE: it don't come easy. Health Data Manag. 2009;17(1):18-20, 22, 24 passim.
https://psnet.ahrq.gov/issue/cpoe-it-dont-come-easy
Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE)
systems could reduce medical errors…
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psnet.ahrq.gov/node/42332/psn-pdf
June 12, 2013 - Quality improvement through implementation of
discharge order reconciliation.
June 12, 2013
Lu Y, Clifford P, Bjorneby A, et al. Quality improvement through implementation of discharge order
reconciliation. Am J Health Syst Pharm. 2013;70(9):815-20. doi:10.2146/ajhp120050.
https://psnet.ahrq.gov/issue/quality-impr…
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psnet.ahrq.gov/node/40568/psn-pdf
June 29, 2011 - Tubing misconnections: normalization of deviance.
June 29, 2011
Simmons D, Symes L, Guenter P, et al. Tubing misconnections: normalization of deviance. Nutr Clin Pract.
2011;26(3):286-293. doi:10.1177/0884533611406134.
https://psnet.ahrq.gov/issue/tubing-misconnections-normalization-deviance
Analyzing published ca…
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psnet.ahrq.gov/node/41411/psn-pdf
October 19, 2012 - Minnesota Hospital Association Statewide Project: SAFE
from FALLS.
October 19, 2012
Apold J, Quigley PA. Minnesota Hospital Association Statewide Project: SAFE from FALLS. J Nurs Care
Qual. 2012;27(4):299-306. doi:10.1097/NCQ.0b013e3182599d1b.
https://psnet.ahrq.gov/issue/minnesota-hospital-association-statewide-p…
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psnet.ahrq.gov/node/35382/psn-pdf
October 05, 2005 - Rx for a better prescription. Hospital bans doctors from
using confusing medical abbreviations.
October 5, 2005
Hall J. Fredericksburg Times. September 25, 2005
https://psnet.ahrq.gov/issue/rx-better-prescription-hospital-bans-doctors-using-confusing-medical-
abbreviations
This article presents one hospital’s pro…
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psnet.ahrq.gov/node/47556/psn-pdf
November 28, 2018 - Improving Diagnosis.
November 28, 2018
Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70.
https://psnet.ahrq.gov/issue/improving-diagnosis
This special issue raises awareness of challenges to reducing diagnostic error. Articles discuss insights
from experts about how to improve diagnosis, t…
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digital.ahrq.gov/ahrq-funded-projects/integrating-contextual-factors-clinical-decision-support-reduce-contextual/citation/contextualizing
January 01, 2023 - Contextualizing care: An essential and measurable clinical competency.
Citation
Weiner SJ. Contextualizing care: An essential and measurable clinical competency. Patient Educ Couns. 2022 Mar;105(3):594-598. doi: 10.1016/j.pec.2021.06.016. Epub 2021 Jun 15. PMID: 34158194.
Link
https://pubmed.n…
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psnet.ahrq.gov/node/42493/psn-pdf
August 14, 2013 - Partnering to prevent falls: using a multimodal
multidisciplinary team.
August 14, 2013
Volz TM, Swaim J. Partnering to prevent falls: using a multimodal multidisciplinary team. J Nurs Adm.
2013;43(6):336-41. doi:10.1097/NNA.0b013e3182942c5a.
https://psnet.ahrq.gov/issue/partnering-prevent-falls-using-multimodal-m…
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digital.ahrq.gov/organization/mainegeneral-medical-center
January 01, 2023 - Mainegeneral Medical Center
Improving Health Information Technology Implementation in a Rural Health System - 2008
Principal Investigator
Mingle, Daniel
Project Name
Improving Health Information Technology Implementation in a Rural Health System
…
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psnet.ahrq.gov/node/43055/psn-pdf
May 01, 2017 - AHRQ's Safety Program for Ambulatory Surgery.
May 1, 2017
Health Research & Educational Trust. Rockville, MD: Agency for Healthcare Research and Quality; May
2017. AHRQ Publication No. 16(17)-0019-1-EF.
https://psnet.ahrq.gov/issue/ahrqs-safety-program-ambulatory-surgery
This report provides information about a na…
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effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pdf/epc-child-adolesc-mental-health-grand-rounds.pptx
May 22, 2025 - Increased reporting of risk in schools/communities with marginalized groups, limited evidence that reduces
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/dementia-nursing-home-characteristics_executive.pdf
October 01, 2012 - Findings of moderate SOE indicate that pleasant sensory
stimulation reduces resident agitation.
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psnet.ahrq.gov/issue/impact-electronic-alert-notification-system-embedded-radiologists-workflow-closed-loop
November 26, 2014 - Study
Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis.
Citation Text:
Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in radiolo…
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www.ahrq.gov/es/programs/index.html?page=3
Digital Healthcare Research Advancing healthcare quality, safety, and effectiveness through the evolving digital healthcare ecosystem. More
PSNet Discover the latest literature, news, and expert commentary on patient safety topics. More
CAHPS The CAHPS program aims to advance our scientific …
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops101-3-gray-2018.pdf
January 01, 2018 - Understanding SOPS Surveys: A Primer for New Users - Gray
Overview of the SOPS Surveys
10
Laura Gray, MPH
Senior Study Director
User Network for the AHRQ Surveys on Patient
Safety Culture (SOPS)
Westat
What is Patient Safety Culture?
11
12
AHRQ Surveys on Patient Safety Culture
Surveys of providers and st…