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psnet.ahrq.gov/issue/call-action-next-steps-advance-diagnosis-education-health-professions
November 25, 2020 - Commentary
A call to action: next steps to advance diagnosis education in the health professions.
Citation Text:
Graber ML, Holmboe ES, Stanley J, et al. A call to action: next steps to advance diagnosis education in the health professions. Diagnosis (Berl). 2022;9(2):166-175. doi:10.151…
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psnet.ahrq.gov/issue/frontline-providers-and-patients-perspectives-improving-diagnostic-safety-emergency
May 15, 2024 - Study
Frontline providers' and patients' perspectives on improving diagnostic safety in the emergency department: a qualitative study.
Citation Text:
Mangus CW, James TG, Parker SJ, et al. Frontline providers' and patients' perspectives on improving diagnostic safety in the emergency dep…
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psnet.ahrq.gov/issue/improving-patient-handoffs-and-transitions-through-adaptation-and-implementation-i-pass
September 23, 2020 - Study
Improving patient handoffs and transitions through adaptation and implementation of I-PASS across multiple handoff settings.
Citation Text:
Blazin LJ, Sitthi-Amorn J, Hoffman JM, et al. Improving patient handoffs and transitions through adaptation and implementation of I-PASS acros…
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psnet.ahrq.gov/issue/team-cognition-handoffs-relating-system-factors-team-cognition-functions-and-outcomes-two
February 16, 2022 - Study
Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes.
Citation Text:
Wooldridge AR, Carayon P, Hoonakker PLT, et al. Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two hand…
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psnet.ahrq.gov/curated-library/covid-19-pandemic-impact-healthcare-associated-conditions
July 21, 2025 - Breadcrumb
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COVID-19 Pandemic Impact on Healthcare Associated Conditions
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Created By: Sam W…
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psnet.ahrq.gov/issue/referrals-infection-control-breaches-public-health-authorities-ambulatory-care-settings
December 09, 2020 - Study
Referrals of infection control breaches to public health authorities: ambulatory care settings experience, 2017.
Citation Text:
Braun B, Chitavi SO, Perkins KM, et al. Referrals of infection control breaches to public health authorities: ambulatory care settings experience, 2017. J…
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psnet.ahrq.gov/issue/adopting-real-time-surveillance-dashboards-component-enterprisewide-medication-safety
June 27, 2018 - Study
Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.
Citation Text:
Waitman LR, Phillips IE, McCoy AB, et al. Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy. Jt Comm J Q…
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psnet.ahrq.gov/issue/how-can-specialist-investigation-agencies-inform-system-wide-learning-patient-safety
January 29, 2014 - Commentary
How can specialist investigation agencies inform system-wide learning for patient safety? A qualitative study of perspectives on the early years of the English Healthcare Safety Investigation Branch.
Citation Text:
Crompton A, Waring J, Macrae C, et al. How can specialist inv…
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psnet.ahrq.gov/issue/efficacy-and-unintended-consequences-hard-stop-alerts-electronic-health-record-systems
March 14, 2022 - Review
Emerging Classic
Efficacy and unintended consequences of hard-stop alerts in electronic health record systems: a systematic review.
Citation Text:
Powers EM, Shiffman RN, Melnick ER, et al. Efficacy and unintended consequences of hard-stop alerts in elect…
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psnet.ahrq.gov/issue/use-expedited-review-tool-screen-prior-diagnostic-error-emergency-department-patients
December 16, 2020 - Study
Use of an expedited review tool to screen for prior diagnostic error in emergency department patients.
Citation Text:
Hudspeth J, El-Kareh R, Schiff G. Use of an expedited review tool to screen for prior diagnostic error in emergency department patients. Appl Clin Inform. 2015;06(0…
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psnet.ahrq.gov/issue/longitudinal-medication-reconciliation-hospital-admission-discharge-and-post-discharge
August 19, 2020 - Study
Longitudinal medication reconciliation at hospital admission, discharge and post-discharge.
Citation Text:
Daliri S, Bouhnouf M, van de Meerendonk HWPC, et al. Longitudinal medication reconciliation at hospital admission, discharge and post-discharge. Res Social Adm Pharm. 2020;17(…
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psnet.ahrq.gov/issue/summary-and-frequency-barriers-adoption-cpoe-us
March 17, 2021 - Review
Summary and frequency of barriers to adoption of CPOE in the US.
Citation Text:
Kruse CS, Goetz K. Summary and frequency of barriers to adoption of CPOE in the U.S. J Med Syst. 2015;39(2):15. doi:10.1007/s10916-015-0198-2.
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psnet.ahrq.gov/issue/association-nurse-engagement-and-nurse-staffing-patient-safety
January 22, 2016 - Study
Emerging Classic
Association of nurse engagement and nurse staffing on patient safety.
Citation Text:
Carthon MB, Hatfield L, Plover C, et al. Association of nurse engagement and nurse staffing on patient safety. J Nurs Care Qual. 2019;34(1):40-46. doi:10.…
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psnet.ahrq.gov/issue/improved-pain-resolution-hospitalized-patients-through-targeting-pain-mismanagement-medical
March 24, 2019 - Study
Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error.
Citation Text:
Okon TR, Lutz PS, Liang H. Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error. J Pain Symptom Manage.…
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psnet.ahrq.gov/issue/microbiological-evaluation-two-hand-hygiene-procedures-achieved-healthcare-workers-during
June 13, 2011 - Study
Microbiological evaluation of two hand hygiene procedures achieved by healthcare workers during routine patient care: a randomized study.
Citation Text:
Kac G, Podglajen I, Gueneret M, et al. Microbiological evaluation of two hand hygiene procedures achieved by healthcare workers…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
August 01, 2022 - Event Investigation and Analysis Guide: Appendix D
CANDOR Tool
PROCESS
QUESTIONS TO REVIEW
Y/N
CONTRIBUTING OR CAUSAL FACTOR Y/N
FINDINGS /
COMMENTS
COMMUNICATION
Did all caregivers have access to all pertinent information needed to make the best decisions for the patient? (e.g.,…
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psnet.ahrq.gov/issue/starting-elective-cardiac-surgery-after-3-pm-does-not-impact-patient-morbidity-mortality-or
February 12, 2020 - Study
Starting elective cardiac surgery after 3 pm does not impact patient morbidity, mortality, or hospital costs.
Citation Text:
Axtell AL, Moonsamy P, Melnitchouk S, et al. Starting elective cardiac surgery after 3 pm does not impact patient morbidity, mortality, or hospital costs. J …
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psnet.ahrq.gov/issue/disciplinary-action-medical-boards-and-prior-behavior-medical-schools
October 19, 2022 - Study
Classic
Disciplinary action by medical boards and prior behavior in medical schools.
Citation Text:
Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. 2005;353(25):2673-82…
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psnet.ahrq.gov/issue/strategies-prevent-healthcare-associated-infections-through-hand-hygiene
July 03, 2014 - Commentary
Strategies to prevent healthcare-associated infections through hand hygiene.
Citation Text:
Ellingson K, Haas JP, Aiello AE, et al. Strategies to prevent healthcare-associated infections through hand hygiene. Infect Control Hosp Epidemiol. 2014;35(8):937-960. doi:10.1086/67714…
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psnet.ahrq.gov/issue/does-seasonal-variation-orthopaedic-trauma-volume-correlate-adverse-hospital-events-and
May 25, 2022 - Study
Does seasonal variation in orthopaedic trauma volume correlate with adverse hospital events and burnout?
Citation Text:
Waldron J, Denisiuk M, Sharma R, et al. Does seasonal variation in orthopaedic trauma volume correlate with adverse hospital events and burnout? Injury. 2022;53(6…