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psnet.ahrq.gov/node/836972/psn-pdf
April 20, 2022 - Diagnostic Centers of Excellence: Partnerships to
Improve Diagnostic Safety and Quality (R18).
April 20, 2022
Rockville, MD: Agency for Healthcare Research and Quality; April 7, 2022. RFA-HS-22-008.
https://psnet.ahrq.gov/issue/diagnostic-centers-excellence-partnerships-improve-diagnostic-safety-and-
quality-r18
…
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psnet.ahrq.gov/node/846455/psn-pdf
March 22, 2023 - Diagnostic Centers of Excellence (X01 Clinical Trial Not
Allowed).
March 22, 2023
PAR-23-120. Bethesda, MD: National Institutes of Health; March 7, 2023
https://psnet.ahrq.gov/issue/diagnostic-centers-excellence-x01-clinical-trial-not-allowed
Approaching diagnosis as a team activity is seen as a key approach to di…
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psnet.ahrq.gov/node/60656/psn-pdf
July 08, 2020 - COVID-19: to be or not to be; that is the diagnostic
question.
July 8, 2020
Coleman JJ, Manavi K, Marson EJ, et al. COVID-19: to be or not to be; that is the diagnostic question.
Postgrad Med J. 2020;96(1137):392-398. doi:10.1136/postgradmedj-2020-137979.
https://psnet.ahrq.gov/issue/covid-19-be-or-not-be-diagnost…
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psnet.ahrq.gov/node/46630/psn-pdf
November 15, 2017 - Patient Safety in the Office-Based Practice Setting.
November 15, 2017
Philadelphia, PA: American College of Physicians; 2017.
https://psnet.ahrq.gov/issue/patient-safety-office-based-practice-setting
Patient safety in the ambulatory setting is gaining traction as a focus for research, intervention, and policy.
Th…
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psnet.ahrq.gov/node/73256/psn-pdf
May 12, 2021 - Addiction treatment providers in Pa. face little state
scrutiny despite harm to clients.
May 12, 2021
Pattani A, Mahon E. Kaiser Health News. April 30, 2021.
https://psnet.ahrq.gov/issue/addiction-treatment-providers-pa-face-little-state-scrutiny-despite-harm-clients
Systemic oversight weaknesses and lack of…
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psnet.ahrq.gov/node/47412/psn-pdf
October 31, 2018 - The systems approach at the sharp end.
October 31, 2018
Cross SRH. The systems approach at the sharp end. Future Healthc J. 2019;5(3):176-180.
doi:10.7861/futurehosp.5-3-176.
https://psnet.ahrq.gov/issue/systems-approach-sharp-end
Systems solutions are often focused on creating improvements at the organizational o…
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psnet.ahrq.gov/node/843095/psn-pdf
January 25, 2023 - Eliminating racial and ethnic disparities causing mortality
and morbidity in pregnant and postpartum patients.
January 25, 2023
Sentinel Event Alert. January 17, 2023:(66):1-5.
https://psnet.ahrq.gov/issue/eliminating-racial-and-ethnic-disparities-causing-mortality-and-morbidity-
pregnant-and
Racial and ethnic in…
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide168.html
October 01, 2014 - 168. Components of Intensive Treatment (Continued)
Treating Tobacco Use and Dependence: 2008 Update
Text version of slide presentation.
Medication
Every smoker should be offered medications endorsed in this Guideline, except where contraindicated or for specific populations for which there is insu…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-e.pdf
September 01, 2015 - Appendix E. Poster on Urinary Catheter Risks and Indications
AHRQ Safety Program for Reducing CAUTI in Hospitals
Appendix E. Poster on Urinary Catheter Risks
and Indications
■ Acute urinary retention or obstruction
■ Perioperative use in selected surgeries
■ Assistance of healing of severe perineal an…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfeprimarycare-infographic.pdf
April 01, 2018 - Guide Promotional Postcard
Did you know...Patient safety issues
in primary care are real.
Annually,
1 in 20 outpatients experiences a diagnostic error
55%
of patients said
diagnostic errors
were a chief concern
in outpatient visits
1 in 9
ED admissions
are related to an
adverse drug event
An estimated …
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psnet.ahrq.gov/node/39119/psn-pdf
November 25, 2009 - Effect of a weight-based prescribing method within an
electronic health record on prescribing errors.
November 25, 2009
Ginzburg R, Barr WB, Harris M, et al. Effect of a weight-based prescribing method within an electronic
health record on prescribing errors. Am J Health Syst Pharm. 2009;66(22):2037-41.
doi:10.214…
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psnet.ahrq.gov/node/36711/psn-pdf
July 25, 2011 - Designing decision support for insulin ordering in a
computerized provider order entry system.
July 25, 2011
Wright L, Feldott CC, Hargrove FR. Designing Decision Support for Insulin Ordering in a Computerized
Provider Order Entry System. Hosp Pharm. 2010;42(2). doi:10.1310/hpj4202-158.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/43229/psn-pdf
June 04, 2014 - Liquid medication dosing errors in children: role of
provider counseling strategies.
June 4, 2014
Yin S, Dreyer BP, Moreira HA, et al. Liquid medication dosing errors in children: role of provider counseling
strategies. Acad Pediatr. 2014;14(3):262-70. doi:10.1016/j.acap.2014.01.003.
https://psnet.ahrq.gov/issue/l…
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psnet.ahrq.gov/node/47925/psn-pdf
August 21, 2019 - Second victims and mindfulness: a systematic review.
August 21, 2019
S Miller C, Scott SD, Beck M. Second victims and mindfulness: a systematic review. J Patient Saf Risk
Manag. 2019;24(3):108-117. doi:10.1177/2516043519838176.
https://psnet.ahrq.gov/issue/second-victims-and-mindfulness-systematic-review
The secon…
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psnet.ahrq.gov/node/43379/psn-pdf
August 14, 2014 - Unit of measurement used and parent medication dosing
errors.
August 14, 2014
Yin S, Dreyer BP, Ugboaja DC, et al. Unit of measurement used and parent medication dosing errors.
Pediatrics. 2014;134(2):e354-61. doi:10.1542/peds.2014-0395.
https://psnet.ahrq.gov/issue/unit-measurement-used-and-parent-medication-dosi…
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psnet.ahrq.gov/node/44990/psn-pdf
July 11, 2017 - Automatic errors: a case series on the errors inherent in
electronic prescribing.
July 11, 2017
Lourenco LM, Bursua A, Groo VL. Automatic Errors: A Case Series on the Errors Inherent in Electronic
Prescribing. J Gen Intern Med. 2016;31(7):808-811. doi:10.1007/s11606-016-3606-5.
https://psnet.ahrq.gov/issue/automat…
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psnet.ahrq.gov/node/44358/psn-pdf
September 24, 2016 - Interruptions and medication administration in critical
care.
September 24, 2016
Bower R, Jackson C, Manning JC. Interruptions and medication administration in critical care. Nurs Crit
Care. 2015;20(4):183-95. doi:10.1111/nicc.12185.
https://psnet.ahrq.gov/issue/interruptions-and-medication-administration-critical…
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psnet.ahrq.gov/node/35836/psn-pdf
March 28, 2011 - Use of a standardized protocol to decrease medication
errors and adverse events related to sliding scale insulin.
March 28, 2011
Donihi AC, DiNardo MM, Devita MA, et al. Use of a standardized protocol to decrease medication errors
and adverse events related to sliding scale insulin. Qual Saf Health Care. 2006;15(2)…
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psnet.ahrq.gov/node/50387/psn-pdf
September 25, 2019 - Special Issue on Prescription Drug Misuse.
September 25, 2019
Rickles NM, Fleming ML, Björnsdottir I, eds. Res Social Adm Pharm. 2019;15:907-1056.
https://psnet.ahrq.gov/issue/special-issue-prescription-drug-misuse
This special issue reviews research initiatives exploring persistent challenges associated with the
…
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psnet.ahrq.gov/node/44298/psn-pdf
July 08, 2015 - Preparing challenging medications for barcode scanning.
July 8, 2015
Waxlax TJ. Preparing challenging medications for barcode scanning. Am J Health Syst Pharm.
2015;72(13):1089-90. doi:10.2146/ajhp140454.
https://psnet.ahrq.gov/issue/preparing-challenging-medications-barcode-scanning
Barcode scanning can reduce me…