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psnet.ahrq.gov/issue/automated-detection-look-alikesound-alike-medication-errors
August 28, 2019 - Study
Automated detection of look-alike/sound-alike medication errors.
Citation Text:
Rash-Foanio C, Galanter W, Bryson M, et al. Automated detection of look-alike/sound-alike medication errors. Am J Health Syst Pharm. 2017;74(7):521-527. doi:10.2146/ajhp150690.
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psnet.ahrq.gov/issue/caught-middle-resident-perspective-influences-learning-environment-perpetuate-mistreatment
September 04, 2019 - Commentary
Caught in the middle: a resident perspective on influences from the learning environment that perpetuate mistreatment.
Citation Text:
Bynum WE, Lindeman B. Caught in the Middle: A Resident Perspective on Influences From the Learning Environment That Perpetuate Mistreatment. Ac…
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psnet.ahrq.gov/issue/using-voluntary-reports-physicians-learn-diagnostic-errors-emergency-medicine
February 17, 2016 - Study
Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine.
Citation Text:
Okafor N, Payne VL, Chathampally Y, et al. Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine. Emerg Med J. 2016;33(4):245-252. d…
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psnet.ahrq.gov/issue/physician-spending-and-subsequent-risk-malpractice-claims-observational-study
May 01, 2015 - Study
Classic
Physician spending and subsequent risk of malpractice claims: observational study.
Citation Text:
Jena AB, Schoemaker L, Bhattacharya J, et al. Physician spending and subsequent risk of malpractice claims: observational study. BMJ. 2015;351:h5516. …
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psnet.ahrq.gov/issue/embracing-errors-simulation-based-training-effect-error-training-retention-and-transfer
May 23, 2013 - Study
Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills.
Citation Text:
Gardner AK, Abdelfattah K, Wiersch J, et al. Embracing Errors in Simulation-Based Training: The Effect of Error Training on Retent…
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psnet.ahrq.gov/issue/defining-health-information-technology-related-errors-new-developments-err-human
December 06, 2023 - Commentary
Classic
Defining health information technology–related errors: new developments since To Err Is Human.
Citation Text:
Sittig DF, Singh H. Defining health information technology-related errors: new developments since to err is human. Arch Intern Med.…
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psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system
April 19, 2023 - Book/Report
Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.
Citation Text:
Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. Washington, DC: Department of Vet…
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psnet.ahrq.gov/issue/adverse-events-and-hospital-acquired-conditions-associated-potential-low-value-care-medicare
May 19, 2021 - Study
Adverse events and hospital-acquired conditions associated with potential low-value care in Medicare beneficiaries.
Citation Text:
Chalmers K, Gopinath V, Brownlee S, et al. Adverse events and hospital-acquired conditions associated with potential low-value care in Medicare benefic…
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psnet.ahrq.gov/issue/personal-health-records-randomized-trial-effects-elder-medication-safety
November 16, 2022 - Study
Personal health records: a randomized trial of effects on elder medication safety.
Citation Text:
Chrischilles EA, Hourcade JP, Doucette W, et al. Personal health records: a randomized trial of effects on elder medication safety. J Am Med Inform Assoc. 2014;21(4):679-86. doi:10.113…
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psnet.ahrq.gov/issue/two-year-longitudinal-assessment-physicians-perceptions-after-replacement-longstanding
December 31, 2014 - Study
Two-year longitudinal assessment of physicians' perceptions after replacement of a longstanding homegrown electronic health record: does a J-curve of satisfaction really exist?
Citation Text:
Hanauer DA, Branford GL, Greenberg G, et al. Two-year longitudinal assessment of physician…
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psnet.ahrq.gov/issue/bone-break-hot-debrief-tool-reduce-second-victim-syndrome-nurses
August 02, 2015 - Study
BONE break: a hot debrief tool to reduce second victim syndrome for nurses.
Citation Text:
Hess A, Flicek T, Watral AT, et al. BONE break: a hot debrief tool to reduce second victim syndrome for nurses. Jt Comm J Qual Patient Saf. 2024;50(9):673-677. doi:10.1016/j.jcjq.2024.05.005.…
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psnet.ahrq.gov/issue/establishing-multi-institutional-quality-and-patient-safety-consortium-collaboration-across
June 24, 2009 - Commentary
Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school.
Citation Text:
Hillman E, Paul J, Neustadt M, et al. Establishing a multi-institutional quality and patient safety consortium: collab…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cad-pci-bypass_addendum.pdf
February 01, 2010 - Additionally, we checked for any violation of
the proportional hazards assumption by testing for a correlation
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digital.ahrq.gov/sites/default/files/docs/publication/r21hs020323-mollica-final-report-2014.pdf
January 01, 2014 - The Virtual Patient for Improving Quality of Care in Primary Healthcare - Final Report
The Virtual Patient for Improving Quality of Care in Primary Healthcare
Principal Investigator and Team Members:
PI: Richard F. Mollica, MD, MAR; J…
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psnet.ahrq.gov/web-mm/transfusion-slip
June 14, 2011 - Transfusion "Slip"
Citation Text:
Kaplan HS. Transfusion "Slip". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
October 01, 2013 - New Patient Mistakenly Checked in as Another
Citation Text:
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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www.ahrq.gov/ncepcr/reports/2025-annual-report/behavioral-health.html
August 01, 2025 - AHRQ’s Investments in Primary Care Research for 2023 and 2024
Behavioral Health and Substance Use Disorders
Previous Page Next Page
Table of Contents
AHRQ’s Investments in Primary Care Research for 2023 and 2024
Acknowledgements and Authors
Message from the Director of AHRQ’s National Center f…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-rr-webcast-011124-elliott.pdf
September 30, 2021 - CAHPS Program: Improving Response Rates and Representativeness - The CAHPS Hospital, CAHPS Hospice, and MA/PDP CAHPS Surveys: Lessons Learned from Recent Mode Experiments
The CAHPS Hospital, CAHPS Hospice,
and MA/PDP CAHPS Surveys:
Lessons Learned from Recent Mode Experiments
Marc Elliott
Senior Principal Researc…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/RPB3rmcS9CK_eXPdzXSxZg
July 01, 2010 - Preventive Services Task Force recom
mended bone density testing for women 65 years or older
and women … Reasons for this are unclear,
although the differing recommendations for identifying
candidates for testing … and treatment, confusion in inter
preting results of testing, and fragmentation of health
care may … Patterns of bone mineral density testing: current guidelines, testing rates, and
interventions. … Decision rules for selecting women for bone mineral density testing:
application in postmenopausal women
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cds.ahrq.gov/sites/default/files/cds/artifact/106/AMIA_presentation.pptx
January 01, 2012 - Healthy Weight
Stage 1:
Freehand mockup
Stage 2
Wireframe mockup
Stage 3
Interactive module
Stage 4
User testing … Stage 1
Quick, easy, low overhead, adaptable
Stage 2
Layout, spacing, internal workflow (white box testing … Testing before implementation
Everything functions as expected
Patient data is appropriately handled … The CDS does not break the EHR
Testing after implementation
How do different clinical workflows impact … is possible
Even minimally tested CDS can have an immediate impact on patient care, but inadequate testing