-
psnet.ahrq.gov/issue/changes-physician-practice-patterns-after-implementation-communication-and-resolution-program
September 01, 2018 - Study
Changes in physician practice patterns after implementation of a communication-and-resolution program.
Citation Text:
Helmchen LA, Lambert BL, McDonald TB. Changes in Physician Practice Patterns after Implementation of a Communication-and-Resolution Program. Health Serv Res. 2016;5…
-
psnet.ahrq.gov/issue/systematic-review-falls-hospital-patients-communication-disability-highlighting-invisible
April 15, 2016 - Review
A systematic review of falls in hospital for patients with communication disability: highlighting an invisible population.
Citation Text:
Hemsley B, Steel J, Worrall L, et al. A systematic review of falls in hospital for patients with communication disability: Highlighting an invi…
-
psnet.ahrq.gov/issue/mandatory-influenza-vaccination-health-care-workers-new-standard-care-matter-patient-safety
September 13, 2023 - Commentary
Mandatory influenza vaccination for health care workers as the new standard of care: a matter of patient safety and nonmaleficent practice.
Citation Text:
Cortes-Penfield N. Mandatory influenza vaccination for health care workers as the new standard of care: a matter of patien…
-
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/blood-pressure-flowchart.pdf
June 02, 2025 - controlling high blood pressure
Controlling High Blood
Pressure
Was the patient aged 18 years or
older on the first day of the
measurement period?
Yes
Was the patient aged 85 years or
younger on the last day of the
measurement period?
Yes
No
Did the patient have at least one
face to face visit with an e…
-
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/smoking-cessation-flowchart.pdf
June 02, 2025 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Preventive Care and
Screening: Tobacco Use:
Screening and Cessation
Intervention
Was the patient aged 18 years or
older on the first day of the
measurement period?
Did the patient have at least two
face to face visits with an e…
-
psnet.ahrq.gov/issue/making-infection-prevention-and-control-everyones-business-hospital-staff-views-patient
April 29, 2015 - Study
Making infection prevention and control everyone's business? Hospital staff views on patient involvement.
Citation Text:
Sutton E, Brewster L, Tarrant C. Making infection prevention and control everyone's business? Hospital staff views on patient involvement. Health Expect. 2019;22…
-
psnet.ahrq.gov/issue/design-retrospective-patient-record-study-occurrence-adverse-events-among-patients-dutch
December 29, 2014 - Study
Design of a retrospective patient record study on the occurrence of adverse events among patients in Dutch hospitals.
Citation Text:
Zegers M, de Bruijne M, Wagner C, et al. Design of a retrospective patient record study on the occurrence of adverse events among patients in Dutch…
-
psnet.ahrq.gov/issue/retrieval-medicine-review-and-guide-uk-practitioners-part-2-safety-patient-retrieval-systems
March 09, 2016 - Commentary
Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems.
Citation Text:
Hearns S, Shirley PJ. Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems. Emerg Med J. 2006;23(12):9…
-
psnet.ahrq.gov/issue/teaching-internal-medicine-residents-quality-improvement-and-patient-safety-lean-thinking
March 28, 2012 - Commentary
Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach.
Citation Text:
Kim CS, Lukela MP, Parekh V, et al. Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach. Am J Med Qual. 201…
-
psnet.ahrq.gov/issue/predicting-patient-complaints-hospital-settings
February 27, 2008 - Study
Predicting patient complaints in hospital settings.
Citation Text:
Kline TJB, Willness C, Ghali WA. Predicting patient complaints in hospital settings. Qual Saf Health Care. 2008;17(5):346-50. doi:10.1136/qshc.2007.024281.
Copy Citation
Format:
DOI Google Scholar Pu…
-
www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/resources/qapi-leadership-rounding-guide-centers-for-medicare.pdf
June 02, 2025 - QAPI Leadership Rounding Guide
Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.
Directions: Leadership rounding is a process where leaders (e.g., administrator, department heads, and nurse
managers) are out in the building with staff and residents, t…
-
psnet.ahrq.gov/issue/retrospective-analysis-reported-suicide-deaths-and-attempts-veterans-health-administration
November 17, 2021 - Study
Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses and inpatient units.
Citation Text:
Mills PD, Soncrant C, Gunnar W. Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses an…
-
psnet.ahrq.gov/issue/facility-delirium-programs-patient-safety-strategy-systematic-review
March 13, 2013 - Review
In-facility delirium programs as a patient safety strategy: a systematic review.
Citation Text:
Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):375-80. doi:10.7326/0003-4819-158…
-
psnet.ahrq.gov/issue/elopement-evidence-based-mitigation-and-management
October 19, 2022 - Study
Elopement: evidence-based mitigation and management.
Citation Text:
Marlett JE, Vacovsky BA, Krug EA, et al. Elopement: evidence‐based mitigation and management. Worldviews Evid Based Nurs. 2024;20(6):634-641. doi:10.1111/wvn.12683.
Copy Citation
Format:
DOI Google Sc…
-
psnet.ahrq.gov/issue/effect-automated-alerts-provider-ordering-behavior-outpatient-setting
November 23, 2016 - Study
The effect of automated alerts on provider ordering behavior in an outpatient setting.
Citation Text:
Steele AW, Eisert S, Witter J, et al. The effect of automated alerts on provider ordering behavior in an outpatient setting. PLoS Med. 2005;2(9):e255. doi:10.1371/journal.pmed.…
-
psnet.ahrq.gov/issue/development-medical-checklists-improved-quality-patient-care
March 23, 2011 - Review
Development of medical checklists for improved quality of patient care.
Citation Text:
Hales B, Terblanche M, Fowler R, et al. Development of medical checklists for improved quality of patient care. International Journal for Quality in Health Care. 2007;20(1). doi:10.1093/intqhc…
-
psnet.ahrq.gov/issue/evaluation-registered-nurse-competency-processes-veterans-health-administration-facilities
April 26, 2006 - Book/Report
Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities.
Citation Text:
Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities. Washington, DC: VA Office of Inspector General; April 20, 201…
-
www.ahrq.gov/news/newsroom/case-studies/cquips0901.html
October 01, 2014 - New York City Uses AHRQ Patient Safety Culture Survey to Reduce Patient Harm
Search All Impact Case Studies
November 2008
The New York City Health and Hospitals Corporation (HHC) has integrated the use of AHRQ's Hospital Survey on Patient Safety Culture as a core component of its corporate-wide patient sa…
-
psnet.ahrq.gov/issue/pediatric-residents-decision-making-around-disclosing-and-reporting-adverse-events-importance
January 25, 2017 - Study
Pediatric residents' decision-making around disclosing and reporting adverse events: the importance of social context.
Citation Text:
Coffey M, Thomson K, Tallett S, et al. Pediatric residents' decision-making around disclosing and reporting adverse events: the importance of social…
-
psnet.ahrq.gov/issue/wrong-site-nerve-blocks-systematic-literature-review-guide-principles-prevention
July 22, 2020 - Review
Wrong-site nerve blocks: a systematic literature review to guide principles for prevention.
Citation Text:
Deutsch ES, Yonash RA, Martin DE, et al. Wrong-site nerve blocks: A systematic literature review to guide principles for prevention. J Clin Anesth. 2018;46:101-111. doi:10.10…