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  1. Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. | PSNet

    psnet.ahrq.gov/issue/prevalence-triggers-and-patient-harm-identified-global-trigger-tool-specialized-palliative
    June 14, 2023 - Study Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. Citation Text: Fredheim OMS, Klingenberg E, Lindahl AK. Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. J Palliat Med.…

  2. MyGroupHealth Web Portal and Shared Medical Records with Patients (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/2006Ralston_051211comp.pdf
    May 01, 2006 - MyGroupHealth Web Portal and Shared Medical Records with Patients James D Ralston, MD MPH MyGroupHealth Web Portal and Shared Medical Records with Patients James D Ralston, MD MPH Group Health Center for Health Studies Seattle, Washington James D Ralston, MD MPH Patient Web Portals • Walled online gardens –…

  3. Unanticipated death after discharge home from the emergency department. | PSNet

    psnet.ahrq.gov/issue/unanticipated-death-after-discharge-home-emergency-department
    November 16, 2022 - Study Unanticipated death after discharge home from the emergency department. Citation Text: Sklar DP, Crandall CS, Loeliger E, et al. Unanticipated Death After Discharge Home From the Emergency Department. Ann Emerg Med. 2007;49(6). doi:10.1016/j.annemergmed.2006.11.018. Copy Citati…

  4. BONE break: a hot debrief tool to reduce second victim syndrome for nurses. | PSNet

    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.…

  5. Patient safety and image transfer between referring hospitals and neuroscience centres: could we do better? | PSNet

    psnet.ahrq.gov/issue/patient-safety-and-image-transfer-between-referring-hospitals-and-neuroscience-centres-could
    July 19, 2023 - Study Patient safety and image transfer between referring hospitals and neuroscience centres: could we do better? Citation Text: Crocker M, Cato-Addison WB, Pushpananthan S, et al. Patient safety and image transfer between referring hospitals and neuroscience centres: could we do bette…

  6. Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school. | PSNet

    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…

  7. A qualitative study of why general practitioners may participate in significant event analysis and educational peer assessment. | PSNet

    psnet.ahrq.gov/issue/qualitative-study-why-general-practitioners-may-participate-significant-event-analysis-and
    October 29, 2008 - Study A qualitative study of why general practitioners may participate in significant event analysis and educational peer assessment. Citation Text: Bowie P, McKay J, Dalgetty E, et al. A qualitative study of why general practitioners may participate in significant event analysis and e…

  8. Understanding diagnostic errors in medicine: a lesson from aviation. | PSNet

    psnet.ahrq.gov/issue/understanding-diagnostic-errors-medicine-lesson-aviation
    December 30, 2014 - Study Understanding diagnostic errors in medicine: a lesson from aviation. Citation Text: Singh H, Petersen LA, Thomas EJ. Understanding diagnostic errors in medicine: a lesson from aviation. Qual Saf Health Care. 2006;15(3):159-64. Copy Citation Format: Google Scholar Pu…

  9. Evaluating the medication process in the context of CPOE use: the significance of working around the system. | PSNet

    psnet.ahrq.gov/issue/evaluating-medication-process-context-cpoe-use-significance-working-around-system
    February 23, 2009 - Study Evaluating the medication process in the context of CPOE use: the significance of working around the system. Citation Text: Niazkhani Z, Pirnejad H, van der Sijs H, et al. Evaluating the medication process in the context of CPOE use: the significance of working around the system.…

  10. Information transfer at hospital discharge: a systematic review. | PSNet

    psnet.ahrq.gov/issue/information-transfer-hospital-discharge-systematic-review
    February 21, 2015 - Review Classic Information transfer at hospital discharge: a systematic review. Citation Text: Kattel S, Manning DM, Erwin PJ, et al. Information transfer at hospital discharge: a systematic review. J Patient Saf. 2020;16(1):e25-e33. doi:10.1097/pts.000000000000…

  11. Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database. | PSNet

    psnet.ahrq.gov/issue/patient-safety-trends-2021-analysis-288882-serious-events-and-incidents-nations-largest-event
    May 19, 2021 - Study Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database. Citation Text: Kepner S, Jones RM. Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest eve…

  12. Challenges and strategies for patient safety in primary care: a qualitative study. | PSNet

    psnet.ahrq.gov/issue/challenges-and-strategies-patient-safety-primary-care-qualitative-study
    October 13, 2021 - Study Challenges and strategies for patient safety in primary care: a qualitative study. Citation Text: Yuan CT, Dy SM, Yuanhong Lai A, et al. Challenges and strategies for patient safety in primary care: a qualitative study. Am J Med Qual. 2022;37(5):379-387. doi:10.1097/jmq.00000000000…

  13. Final Research Plan: Falls Prevention in Community-Dwelling Older Adults: Interventions | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/falls-prevention-community-dwelling-older-adults-interventions
    July 21, 2022 - Share to Facebook Share to X Share to WhatsApp Share to Email Print Final Research Plan Falls Prevention in Community-Dwelling Older Adults: Interventions July 21, 2022 Recommendations made by the USPSTF are independent of the U.S. governm…

  14. Physician EHR adoption and potentially preventable hospital admissions among Medicare beneficiaries: panel data evidence, 2010–2013. | PSNet

    psnet.ahrq.gov/issue/physician-ehr-adoption-and-potentially-preventable-hospital-admissions-among-medicare
    February 14, 2024 - Study Physician EHR adoption and potentially preventable hospital admissions among Medicare beneficiaries: panel data evidence, 2010–2013. Citation Text: Lammers EJ, McLaughlin CG, Barna M. Physician EHR Adoption and Potentially Preventable Hospital Admissions among Medicare Beneficiarie…

  15. Systematic review on the frequency and quality of reporting patient and public involvement in patient safety research. | PSNet

    psnet.ahrq.gov/issue/systematic-review-frequency-and-quality-reporting-patient-and-public-involvement-patient
    February 17, 2021 - Review Systematic review on the frequency and quality of reporting patient and public involvement in patient safety research. Citation Text: Hammoud S, Alsabek L, Rogers L, et al. Systematic review on the frequency and quality of reporting patient and public involvement in patient safety…

  16. Application of a digital quality measure for cancer diagnosis in Epic Cosmos. | PSNet

    psnet.ahrq.gov/issue/application-digital-quality-measure-cancer-diagnosis-epic-cosmos
    November 13, 2024 - Study Application of a digital quality measure for cancer diagnosis in Epic Cosmos. Citation Text: Zimolzak AJ, Khan SP, Singh H, et al. Application of a digital quality measure for cancer diagnosis in Epic Cosmos. J Am Med Inform Assoc. 2025;32(1):227-229. doi:10.1093/jamia/ocae253. C…

  17. Summary of USPSTF Final Recommendation: Screening for Syphilis Infection During Pregnancy (pdf file)

    www.uspreventiveservicestaskforce.org/home/getfilebytoken/_CqYnP2r9XUSuDgkPpF9y8
    May 01, 2025 - Summary of USPSTF Final Recommendation: Screening for Syphilis Infection During Pregnancy Clinicians Summary of USPSTF Final Recommendation Screening for Syphilis Infection During Pregnancy May 2025 What does the USPSTF recommend? A Grade For pregnant women: Provi…

  18. Can patients contribute to safer care in meetings with healthcare professionals? A cross-sectional survey of patient perceptions and beliefs. | PSNet

    psnet.ahrq.gov/issue/can-patients-contribute-safer-care-meetings-healthcare-professionals-cross-sectional-survey
    November 22, 2017 - Study Can patients contribute to safer care in meetings with healthcare professionals? A cross-sectional survey of patient perceptions and beliefs. Citation Text: Ericsson C, Skagerström J, Schildmeijer K, et al. Can patients contribute to safer care in meetings with healthcare professio…

  19. Final Report, Year 3: CDS Connect (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/cds-connect-year3-final-report-2019.pdf
    January 01, 2019 - and testing. … CQL Services and the CQL Testing Framework should also be updated to support testing and executing … Update the CQL Testing Framework to support all FHIR resource types: Currently, the CQL Testing Framework … Key work products: Alpha, beta, and production-level prototype tool (CQL Testing Framework); CQL Testing … AHRQ-CDS/CQL Testing Framework. https://github.com/AHRQ-CDS/CQL- Testing-Framework.

  20. PowerPoint Presentation

    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
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