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psnet.ahrq.gov/issue/benchmarking-surgical-incident-reports-using-database-and-triage-system-reduce-adverse
June 18, 2008 - Study
Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes.
Citation Text:
Antonacci AC, Lam S, Lavarias V, et al. Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes. Arch Sur…
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psnet.ahrq.gov/issue/effect-universal-glove-and-gown-use-adverse-events-intensive-care-unit-patients
December 09, 2015 - Study
The effect of universal glove and gown use on adverse events in intensive care unit patients.
Citation Text:
Croft LD, Harris AD, Pineles L, et al. The Effect of Universal Glove and Gown Use on Adverse Events in Intensive Care Unit Patients. Clin Infect Dis. 2015;61(4):545-53. doi:…
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psnet.ahrq.gov/issue/evaluation-consistency-dosing-directions-and-measuring-devices-pediatric-nonprescription
May 31, 2017 - Study
Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.
Citation Text:
Yin S, Wolf MS, Dreyer BP, et al. Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medicati…
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psnet.ahrq.gov/issue/effectiveness-continuous-or-intermittent-vital-signs-monitoring-preventing-adverse-events
July 19, 2023 - Review
Effectiveness of continuous or intermittent vital signs monitoring in preventing adverse events on general wards: a systematic review and meta-analysis.
Citation Text:
Cardona-Morrell M, Prgomet M, Turner RM, et al. Effectiveness of continuous or intermittent vital signs monitorin…
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www.ahrq.gov/research/publications/search.html?page=9
June 01, 2016 - Search Publications
The Agency for Healthcare Research and Quality (AHRQ)'s publications offer practical information to help a variety of health care organizations, providers, and others make care safer in all health care settings. 91 - 100 of 191 Publications displayed
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psnet.ahrq.gov/issue/review-article-improving-hospital-clinical-handover-between-paramedics-and-emergency
February 28, 2024 - Review
Review article: improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient.
Citation Text:
Dawson S, King L, Grantham H. Review article: Improving the hospital clinical handover between paramedics and emergency departme…
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hcup-us.ahrq.gov/datainnovations/clinicaldata/FL15LOINCbriefdescription.jsp
April 15, 2011 - LOINC
An official website of the Department of Health & Human Services
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psnet.ahrq.gov/issue/multicentre-study-develop-medication-safety-package-decreasing-inpatient-harm-omission-time
May 18, 2022 - Study
Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications.
Citation Text:
Graudins LV, Ingram C, Smith BT, et al. Multicentre study to develop a medication safety package for decreasing inpatient harm from omis…
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www.ahrq.gov/news/newsroom/case-studies/202202.html
February 01, 2022 - Henry Ford Hospital's Hematology-Oncology Unit Uses AHRQ Safety Program to Lower Bloodstream Infections
Search All Impact Case Studies
February 2022
Using AHRQ's Comprehensive Unit-based Safety Program ( CUSP ), Henry Ford Hospital in Detroit has reduced the incidence of central line-associated bloodstream …
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psnet.ahrq.gov/issue/impact-electronic-chemotherapy-order-forms-prescribing-errors-urban-medical-center-results
June 13, 2011 - Study
Impact of electronic chemotherapy order forms on prescribing errors at an urban medical center: results from an interrupted time-series analysis.
Citation Text:
Elsaid K, Truong T, Monckeberg M, et al. Impact of electronic chemotherapy order forms on prescribing errors at an urban …
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psnet.ahrq.gov/issue/multifaceted-intervention-improve-patient-safety-incident-reporting-intensive-care-units
January 18, 2023 - Study
Multifaceted intervention to improve patient safety incident reporting in intensive care units.
Citation Text:
Griffeth EM, Gajic O, Schueler N, et al. Multifaceted intervention to improve patient safety incident reporting in intensive care units. J Patient Saf. 2023;19(7):422-428.…
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psnet.ahrq.gov/issue/how-reliable-are-patient-completed-medication-reconciliation-forms-compared-pharmacy-lists
April 24, 2018 - Study
How reliable are patient-completed medication reconciliation forms compared with pharmacy lists?
Citation Text:
Meyer C, Stern M, Woolley W, et al. How reliable are patient-completed medication reconciliation forms compared with pharmacy lists? Am J Emerg Med. 2012;30(7):1048-54.…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/hcbs-2021-webcast-quality-measures.pdf
January 01, 2021 - Introducing a New Database for Users of the CAHPS Home and Community-Based Services (HCBS CAHPS) Survey - BROWN
Looking Forward: HCBS
Quality Measures Alignment
and HCBS CAHPS® Survey
Melanie Brown, PhD, Technical Director
Division of Community Systems Transformation, Disabled and Elderly Health
Programs Group, Ce…
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psnet.ahrq.gov/issue/identifying-hospital-wide-harm-set-icd-9-cm-coded-conditions-associated-increased-cost-length
September 07, 2016 - Study
Identifying hospital-wide harm: a set of ICD-9–CM-coded conditions associated with increased cost, length of stay, and risk of mortality.
Citation Text:
Bankowitz RA, Doyle B, Duan M, et al. Identifying hospital-wide harm: a set of ICD-9-CM-coded conditions associated with increase…
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www.ahrq.gov/hai/cauti-tools/impl-guide/implementation-guide-appendix-o.html
October 01, 2015 - Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
Appendix O. CAUTI Event Report Template
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Table of Contents
Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide
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www.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
September 01, 2025 - Quality and Safety Review System (QSRS)
Retrospectively Reviewing Inpatient Health Records To Identify Adverse Events Medical errors are an ongoing challenge to the healthcare system in the United States. The extent of medical errors in U.S. hospitals was revealed in 2000 when the Institute of Medicine (now the…
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psnet.ahrq.gov/issue/incidence-and-types-preventable-adverse-events-elderly-patients-population-based-review
June 23, 2015 - Study
Classic
Incidence and types of preventable adverse events in elderly patients: population based review of medical records.
Citation Text:
Thomas EJ, Brennan TA. Incidence and types of preventable adverse events in elderly patients: population based revie…
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digital.ahrq.gov/care-setting/ambulatory-clinic
January 01, 2023 - Ambulatory Setting
Development and Assessment of Artificial Intelligence (AI)-Enhanced Pretreatment Peer-review Process to Improve Patient Safety in Radiation Oncology
Description
This research develops and evaluates an artificial intelligence-enhanced pretreatment peer-review…
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psnet.ahrq.gov/issue/interventions-employed-improve-intrahospital-handover-systematic-review
January 20, 2015 - Review
Interventions employed to improve intrahospital handover: a systematic review.
Citation Text:
Robertson ER, Morgan L, Bird S, et al. Interventions employed to improve intrahospital handover: a systematic review. BMJ Qual Saf. 2014;23(7):600-7. doi:10.1136/bmjqs-2013-002309.
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psnet.ahrq.gov/issue/association-adverse-effects-medical-treatment-mortality-united-states-secondary-analysis
November 11, 2020 - Study
Association of adverse effects of medical treatment with mortality in the United States: a secondary analysis of the Global Burden of Diseases, Injuries, and Risk Factors study.
Citation Text:
Sunshine JE, Meo N, Kassebaum NJ, et al. Association of Adverse Effects of Medical Treatm…