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www.ahrq.gov/news/newsroom/case-studies/ktcquips92.html
October 01, 2014 - Maryland Hospitals Revise Medication Reconciliation Process With AHRQ Toolkit
Search All Impact Case Studies
April 2012
After participating in AHRQ-sponsored learning sessions and provider support calls, Delmarva Foundation for Medical Care, the Maryland Quality Improvement Organization (QIO), worked with h…
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psnet.ahrq.gov/issue/evaluating-implementation-rapid-response-team-considering-alternative-outcome-measures
October 19, 2022 - Study
Evaluating implementation of a rapid response team: considering alternative outcome measures.
Citation Text:
Moriarty JP, Schiebel NE, Johnson MG, et al. Evaluating implementation of a rapid response team: considering alternative outcome measures. Int J Qual Health Care. 2014;26(1)…
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psnet.ahrq.gov/issue/association-between-day-delivery-and-obstetric-outcomes-observational-study
January 07, 2015 - Study
Association between day of delivery and obstetric outcomes: observational study.
Citation Text:
Palmer WL, Bottle A, Aylin P. Association between day of delivery and obstetric outcomes: observational study. BMJ. 2015;351:h5774. doi:10.1136/bmj.h5774.
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psnet.ahrq.gov/issue/observational-study-drug-formulation-manipulation-pediatric-versus-adult-inpatients
June 08, 2022 - Study
Observational study of drug formulation manipulation in pediatric versus adult inpatients.
Citation Text:
Spishock S, Meyers R, Robinson CA, et al. Observational Study of Drug Formulation Manipulation in Pediatric Versus Adult Inpatients. J Patient Saf. 2021;17(1):e10-e14. doi:10.1…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/HAP-one-page.docx
November 01, 2019 - Hospital-Acquired Pneumonia
Hospital-Acquired Pneumonia
Diagnosis
· Clinical symptoms of pneumonia (e.g., fever, cough, dyspnea, pleuritic chest pain) PLUS hypoxia PLUS a new radiographic infiltrate that develops at least 48 hours after hospitalization
· Microbiology: either community-associated (e.g., Stre…
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psnet.ahrq.gov/issue/impact-non-interruptive-medication-laboratory-monitoring-alerts-ambulatory-care
March 10, 2011 - Study
Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care.
Citation Text:
Lo HG, Matheny ME, Seger DL, et al. Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care. J Am Med Inform Assoc. 2009;16(1):66-71. doi:10.1197/jami…
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psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents
August 09, 2018 - Study
A tool for the concise analysis of patient safety incidents.
Citation Text:
Pham JC, Hoffman C, Popescu I, et al. A Tool for the Concise Analysis of Patient Safety Incidents. Jt Comm J Qual Patient Saf. 2016;42(1):26-33.
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psnet.ahrq.gov/issue/american-geriatrics-society-2019-updated-ags-beers-criteria-potentially-inappropriate
August 16, 2023 - Organizational Policy/Guidelines
Classic
American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
Citation Text:
American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappro…
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psnet.ahrq.gov/issue/limits-safety-organizations-accidents-and-nuclear-weapons
July 28, 2013 - Book/Report
Classic
The Limits of Safety: Organizations, Accidents and Nuclear Weapons.
Citation Text:
The Limits of Safety: Organizations, Accidents and Nuclear Weapons. Sagan SD. Princeton NJ: Princeton University Press; 1993. ISBN: 9780691032214.
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psnet.ahrq.gov/issue/operating-room-briefings-and-wrong-site-surgery
November 26, 2008 - Study
Classic
Operating room briefings and wrong-site surgery.
Citation Text:
Makary MA, Mukherjee A, Sexton B, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204(2):236-43.
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/experience/fullerton-c-et-al
January 01, 2023 - Fullerton C et al. 2006 "Lessons learned from pilot site implementation of an ambulatory electronic health record."
Reference
Fullerton C, Aponte P, Hopkins R III, et al. Lessons learned from pilot site implementation of an ambulatory electronic health record. Baylor University Medical Center Proceedi…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/miller-rh-et
January 01, 2023 - Miller RH et al. 2005 "The value of electronic health records in solo or small group practices."
Reference
Miller RH, West C, Brown TM, et al. The value of electronic health records in solo or small group practices. Health Aff 2005;24(5):1127.
[Link]
Abstract
"We conducted case studies of fo…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-234-headaches-pregnancy-revised-comments.pdf
November 12, 2020 - Disposition of Comments: CER 234 Management of Primary Headaches in Pregnancy
Comparative Effectiveness Review Disposition of Comments Report
Research Review Title: Management of Primary Headaches in Pregnancy
Draft review available for public comment from June 2, 2020 through June 30, 2020. …
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/chaudhry-b-et-al-2006
January 01, 2006 - Chaudhry B et al. 2006 "Systematic review: impact of health information technology on quality, efficiency, and costs of medical care."
Reference
Chaudhry B, Wang J, Wu SY, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Me…
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psnet.ahrq.gov/issue/resolving-productivity-paradox-health-information-technology-time-optimism
November 16, 2022 - Commentary
Resolving the productivity paradox of health information technology: a time for optimism.
Citation Text:
Wachter R, Howell MD. Resolving the Productivity Paradox of Health Information Technology: A Time for Optimism. JAMA. 2018;320(1):25-26. doi:10.1001/jama.2018.5605.
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psnet.ahrq.gov/issue/examining-copy-and-paste-function-use-electronic-health-records
October 21, 2015 - Book/Report
Examining the Copy and Paste Function in the Use of Electronic Health Records.
Citation Text:
Examining the Copy and Paste Function in the Use of Electronic Health Records. Lowry SZ, Ramaiah M, Prettyman SS, et al. Gaithersburg, MD: National Institute of Standards and Technol…
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hcup-us.ahrq.gov/reports/infographics/flus-annual-impact.jsp
May 01, 2020 - Flu's Annual Impact
An official website of the Department of Health & Human Services
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/smith-my-et-al-2007
January 01, 2007 - Smith MY et al. 2007 "Computerized decision-support systems for chronic pain management in primary care."
Reference
Smith MY, Depue JD, Rini C. Computerized decision-support systems for chronic pain management in primary care. Pain Med 2007;8:S155-S166.
Abstract
"Objective: Computerized decis…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Prologue_Battles_Vol2.pdf
June 02, 2025 - Prologue: Culture and Redesign for Improved Patient Safety
Prologue
Culture and Redesign for Improved Patient Safety
James B. Battles, PhD
The articles in this volume explore issues of culture and the redesign of organizations and
clinical practices to improve patient safety. Within this broad theme are f…
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psnet.ahrq.gov/issue/safety-personal-partnering-patients-and-families-safest-care
January 06, 2015 - Book/Report
Safety Is Personal: Partnering With Patients and Families for the Safest Care.
Citation Text:
Safety Is Personal: Partnering With Patients and Families for the Safest Care. NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Boston, MA: National P…