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psnet.ahrq.gov/issue/spoons-systematically-bias-dosing-liquid-medicine
November 03, 2015 - Study
Spoons systematically bias dosing of liquid medicine.
Citation Text:
Wansink B, van Ittersum K. Spoons systematically bias dosing of liquid medicine. Ann Intern Med. 2010;152(1):66-7. doi:10.7326/0003-4819-152-1-201001050-00024.
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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/communication-healthcare-narrative-review-literature-and-practical-recommendations
August 04, 2021 - Review
Communication in healthcare: a narrative review of the literature and practical recommendations.
Citation Text:
Vermeir P, Vandijck D, Degroote S, et al. Communication in healthcare: a narrative review of the literature and practical recommendations. Int J Clin Pract. 2015;69(11):…
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psnet.ahrq.gov/issue/occurrence-potential-patient-safety-events-among-trauma-patients-are-they-random
July 19, 2018 - Study
The occurrence of potential patient safety events among trauma patients: are they random?
Citation Text:
Chang DC, Handly N, Abdullah F, et al. The occurrence of potential patient safety events among trauma patients: are they random? Ann Surg. 2008;247(2):327-34. doi:10.1097/SLA.…
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psnet.ahrq.gov/issue/consequences-running-more-operating-theatres-anaesthetists-staff-them-stochastic-simulation
October 19, 2022 - Study
Consequences of running more operating theatres than anaesthetists to staff them: a stochastic simulation study.
Citation Text:
Paoletti X, Marty J. Consequences of running more operating theatres than anaesthetists to staff them: a stochastic simulation study. Br J Anaesth. 2007…
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psnet.ahrq.gov/issue/accuracy-adverse-drug-event-reports-collected-using-automated-dispensing-system
April 06, 2022 - Study
Accuracy of adverse-drug-event reports collected using an automated dispensing system.
Citation Text:
Romero A, Malone DC. Accuracy of adverse-drug-event reports collected using an automated dispensing system. Am J Health Syst Pharm. 2005;62(13):1375-80.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-bestpractices-web-sopssurveys-yount.pdf
June 02, 2025 - Best Practices for Web-based SOPS Surveys - Yount Slides
Fielding Your Survey
Naomi Yount, Ph.D.
Westat
41
Promoting the Survey
• Publicize on flyers or posters
• Send emails with a letter of support from leadership
• Post information on your intranet
• Discuss at staff meetings
42
Information to Inclu…
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psnet.ahrq.gov/issue/contextual-errors-medical-decision-making-overlooked-and-understudied
May 01, 2020 - Commentary
Contextual errors in medical decision making: overlooked and understudied.
Citation Text:
Weiner SJ, Schwartz A. Contextual Errors in Medical Decision Making: Overlooked and Understudied. Acad Med. 2016;91(5):657-62. doi:10.1097/ACM.0000000000001017.
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psnet.ahrq.gov/issue/comparison-barcode-scanning-pharmacy-technicians-and-pharmacists-visual-checks-final-product
August 31, 2016 - Study
Comparison of barcode scanning by pharmacy technicians and pharmacists' visual checks for final product verification.
Citation Text:
Wang BN-T, Brummond P, Stevenson JG. Comparison of barcode scanning by pharmacy technicians and pharmacists' visual checks for final product verifica…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-166-fecc-tables-13-14.pdf
June 02, 2025 - Section 7.B, Tables 13 and 14
Indicator Indicator Does not live Lives in
ID in MSA MSA
(N=217) (n=625)
Care Coordination Services
Has care coordinator FECC-1 73.5 69.8
Access to care coordinator FECC-2 97.5 96.1
Care coordinator helped to obtain
community services
FECC-3
…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-166-fecc-tables-15-16.pdf
June 02, 2025 - Section 7.E, Tables 15 and 16
Indicator Indicator
ID
English
proficient
(n=1094)
LEP
(n=154)
Care Coordination Services
Has care coordinator
Access to care coordinator
Care coordinator helped to obtain community
services
Care coordinator contact in the last 3 months
Care coo…
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psnet.ahrq.gov/issue/frequent-diagnostic-errors-cardiac-petct-due-misregistration-ct-attenuation-and-emission-pet
December 22, 2018 - Study
Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT attenuation and emission PET images: a definitive analysis of causes, consequences, and corrections.
Citation Text:
Gould L, Pan T, Loghin C, et al. Frequent diagnostic errors in cardiac PET/CT due to misre…
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psnet.ahrq.gov/issue/computer-alert-system-prevent-injury-adverse-drug-events-development-and-evaluation-community
November 01, 2016 - Study
Classic
A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital.
Citation Text:
Raschke RA, Gollihare B, Wunderlich TA, et al. A Computer Alert System to Prevent Injury From Adverse …
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psnet.ahrq.gov/issue/anesthesia-safety-model-or-myth-review-published-literature-and-analysis-current-original
July 13, 2010 - Review
Anesthesia safety: model or myth? A review of the published literature and analysis of current original data.
Citation Text:
Lagasse RS. Anesthesia safety: model or myth? A review of the published literature and analysis of current original data. Anesthesiology. 2002;97(6):1609-17…
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psnet.ahrq.gov/issue/parenteral-nutrition-prescribing-processes-using-computerized-prescriber-order-entry
September 11, 2019 - Study
Parenteral nutrition prescribing processes using computerized prescriber order entry: opportunities to improve safety.
Citation Text:
Hilmas E, Peoples JD. Parenteral nutrition prescribing processes using computerized prescriber order entry: opportunities to improve safety. JPEN …
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psnet.ahrq.gov/issue/limited-health-literacy-barrier-medication-reconciliation-ambulatory-care
March 24, 2010 - Study
Limited health literacy is a barrier to medication reconciliation in ambulatory care.
Citation Text:
Persell SD, Osborn CY, Richard R, et al. Limited health literacy is a barrier to medication reconciliation in ambulatory care. J Gen Intern Med. 2007;22(11):1523-6.
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psnet.ahrq.gov/issue/hospital-costs-associated-adverse-events-gynecological-oncology
March 09, 2022 - Study
Hospital costs associated with adverse events in gynecological oncology.
Citation Text:
Kondalsamy-Chennakesavan S, Gordon LG, Sanday K, et al. Hospital costs associated with adverse events in gynecological oncology. Gynecol Oncol. 2011;121(1):70-5. doi:10.1016/j.ygyno.2010.11.03…
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psnet.ahrq.gov/issue/right-medication-right-dose-right-patient-right-time-and-right-route-how-do-we-select-right
March 02, 2016 - Commentary
Right medication, right dose, right patient, right time, and right route: how do we select the right patient-controlled analgesia (PCA) device?
Citation Text:
Ladak SSJ, Chan VWS, Easty T, et al. Right medication, right dose, right patient, right time, and right route: how d…
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psnet.ahrq.gov/issue/am-i-right-when-i-am-sure-data-consistency-influences-relationship-between-diagnostic
March 18, 2013 - Study
Am I right when I am sure? Data consistency influences the relationship between diagnostic accuracy and certainty.
Citation Text:
Cavalcanti RB, Sibbald M. Am I right when I am sure? Data consistency influences the relationship between diagnostic accuracy and certainty. Acad Med. …
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psnet.ahrq.gov/issue/socio-technical-systems-approach-studying-interruptions-understanding-interrupters
October 03, 2013 - Study
A socio-technical systems approach to studying interruptions: understanding the interrupter's perspective.
Citation Text:
Rivera J. A socio-technical systems approach to studying interruptions: understanding the interrupter's perspective. Appl Ergon. 2014;45(3):747-56. doi:10.1016/…