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psnet.ahrq.gov/issue/applying-hierarchical-task-analysis-medication-administration-errors
December 18, 2017 - Commentary
Applying hierarchical task analysis to medication administration errors.
Citation Text:
Lane R, Stanton NA, Harrison DA. Applying hierarchical task analysis to medication administration errors. Appl Ergon. 2006;37(5):669-79.
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psnet.ahrq.gov/issue/association-between-culture-climate-and-quality-care-primary-health-care-teams
May 30, 2011 - Commentary
The association between culture, climate and quality of care in primary health care teams.
Citation Text:
Hann M, Bower P, Campbell S, et al. The association between culture, climate and quality of care in primary health care teams. Fam Pract. 2007;24(4):323-9.
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psnet.ahrq.gov/issue/its-not-all-about-me-motivating-hand-hygiene-among-health-care-professionals-focusing
May 29, 2019 - Study
It's not all about me: motivating hand hygiene among health care professionals by focusing on patients.
Citation Text:
Grant AM, Hofmann DA. It's not all about me: motivating hand hygiene among health care professionals by focusing on patients. Psychol Sci. 2011;22(12):1494-9. do…
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psnet.ahrq.gov/issue/obstetric-medical-emergency-teams-are-step-forward-maternal-safety
November 04, 2020 - Review
Obstetric medical emergency teams are a step forward in maternal safety!
Citation Text:
Al Kadri HMF. Obstetric medical emergency teams are a step forward in maternal safety!. J Emerg Trauma Shock. 2010;3(4):337-341. doi:10.4103/0974-2700.70755.
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psnet.ahrq.gov/issue/wake-hospital-inquiries-impact-staff-and-safety
January 12, 2022 - Commentary
In the wake of hospital inquiries: impact on staff and safety.
Citation Text:
Dunbar JA, Reddy P, Beresford B, et al. In the wake of hospital inquiries: impact on staff and safety. Med J Aust. 2007;186(2):80-3.
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psnet.ahrq.gov/issue/clinical-questions-raised-clinicians-point-care-systematic-review
May 04, 2022 - Review
Clinical questions raised by clinicians at the point of care: a systematic review.
Citation Text:
Del Fiol G, Workman E, Gorman PN. Clinical questions raised by clinicians at the point of care: a systematic review. JAMA Intern Med. 2014;174(5):710-8. doi:10.1001/jamainternmed.2014…
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psnet.ahrq.gov/issue/adapting-joint-commissions-seven-foundations-safe-and-effective-transitions-care-home
July 10, 2024 - Commentary
Adapting The Joint Commission's seven foundations of safe and effective transitions of care to home.
Citation Text:
Labson MC. Adapting the joint commission's seven foundations of safe and effective transitions of care to home. Home Healthc Now. 2015;33(3):142-6. doi:10.1097/N…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/mcc-summit/mcc-summit-arlene.pdf
November 17, 2020 - Transforming Care for People Living with Multiple Chronic Conditions
Transforming Care for People Living with
Multiple Chronic Conditions
Arlene Bierman, M.D., M.S.
Director, Center for Evidence and Practice Improvement
Agency for Healthcare Research and Quality
November 17, 2020
Why MCC?
• Common, Costly
• H…
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psnet.ahrq.gov/issue/intrahospital-patient-transport-checklists-adverse-events-and-other-considerations-anesthesia
April 24, 2019 - Newspaper/Magazine Article
Intrahospital patient transport: checklists, adverse events, and other considerations for the anesthesia professional.
Citation Text:
Andrew C, Fitzsimons M. Intrahospital patient transport: checklists, adverse events, and other considerations for the anesthesi…
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digital.ahrq.gov/ahrq-funded-projects/interoperable-reusable-and-scalable-shared-decision-aid-navigator-system
August 31, 2025 - An Interoperable, Reusable, and Scalable Shared Decision Aid Navigator System: Supporting the 5 Rights of Patient Shared Decision Making
Project Description
Using interoperable standards to create a reusable, sharable, and scalable system for patient shared decision aids has th…
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psnet.ahrq.gov/issue/definition-quality-and-approaches-its-assessment-vol-1-explorations-quality-assessment-and
May 24, 2015 - Book/Report
Classic
The Definition of Quality and Approaches to Its Assessment. Vol 1. Explorations in Quality Assessment and Monitoring.
Citation Text:
The Definition of Quality and Approaches to Its Assessment. Vol 1. Explorations in Quality Assessment and Mon…
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psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable
August 15, 2012 - Study
Is failure mode and effect analysis reliable?
Citation Text:
Shebl NA, Franklin BD, Barber N. Is failure mode and effect analysis reliable? J Patient Saf. 2009;5(2):86-94. doi:10.1097/PTS.0b013e3181a6f040.
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psnet.ahrq.gov/issue/ahrq-communication-and-optimal-resolution-candor-toolkit
May 25, 2016 - Toolkit
AHRQ Communication and Optimal Resolution (CANDOR) Toolkit.
Citation Text:
AHRQ Communication and Optimal Resolution (CANDOR) Toolkit. Rockville, MD: Agency for Healthcare Research and Quality; May 2016.
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digital.ahrq.gov/2018-year-review/research-summary/simple-mobile-application-key-patient-engagement-reporting-and
January 01, 2018 - A Simple Mobile Application is Key to Patient Engagement in Reporting and Monitoring of Asthma Symptoms
Key Finding and Impact:
A simple app, designed with input from patients, resulted in 92 percent of patients continuing to report their asthma outcomes at the end of the study. A tool like this simple app ma…
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hcup-us.ahrq.gov/db/vars/key_nis/nisnote.jsp
September 01, 2008 - Healthcare Cost and Utilization Project (HCUP) NIS Notes
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
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Espanol
FAQs…
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psnet.ahrq.gov/issue/factors-associated-diagnostic-error-analysis-closed-medical-malpractice-claims
July 13, 2022 - Study
Factors associated with diagnostic error: an analysis of closed medical malpractice claims.
Citation Text:
Grenon V, Szymonifka J, Adler-Milstein J, et al. Factors associated with diagnostic error: an analysis of closed medical malpractice claims. J Patient Saf. 2023;19(3):211-215.…
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hcup-us.ahrq.gov/news/exhibit_booth/NRDBrochure_050218.pdf
May 16, 2018 - What is the NRD?
The Nationwide Readmissions Database (NRD)
is part of the family of databases and software
tools developed for the Healthcare Cost and
Utilization Project (HCUP). The NRD is a unique
and powerful database designed to support
various types of analyses of national readmission
rates for all payers and the…
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psnet.ahrq.gov/issue/safe-use-health-information-technology
December 23, 2016 - Sentinel Event Alerts
Safe use of health information technology.
Citation Text:
Safe use of health information technology. Sentinel Event Alert. March 31, 2015;(54):1-6.
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www.ahrq.gov/talkingquality/plan/pay.html
November 01, 2018 - How Will You Pay for a Health Care Quality Report?
A consumer reporting project is not cheap, although there are ways to reduce costs and spread them across multiple parties (including other sponsors and participating health plans or providers). Data collection costs can range from as little as a few thousand…
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psnet.ahrq.gov/issue/three-perspectives-changes-resident-work-environment-and-duty-hours
September 02, 2020 - Commentary
Three perspectives on changes in resident work environment and duty hours.
Citation Text:
Three perspectives on changes in resident work environment and duty hours. Bilimoria KY, Meyers MO, Mouawad NJ, et al. JAMA Surg. 2017;152(10):903-908.
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