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psnet.ahrq.gov/node/45491/psn-pdf
May 09, 2017 - A systematic review of the types and causes of
prescribing errors generated from using computerized
provider order entry systems in primary and secondary
care.
May 9, 2017
Brown CL, Mulcaster HL, Triffitt KL, et al. A systematic review of the types and causes of prescribing errors
generated from using computerize…
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psnet.ahrq.gov/node/46747/psn-pdf
June 06, 2018 - Tackling ambulatory safety risks through patient
engagement: what 10,000 patients and families say about
safety-related knowledge, behaviors, and attitudes after
reading visit notes.
June 6, 2018
Bell SK, Folcarelli P, Fossa A, et al. Tackling Ambulatory Safety Risks Through Patient Engagement: What
10,000 Patien…
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psnet.ahrq.gov/node/36342/psn-pdf
March 02, 2011 - Missed and delayed diagnoses in the ambulatory setting:
a study of closed malpractice claims.
March 2, 2011
Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study
of closed malpractice claims. Ann Intern Med. 2006;145(7):488-496.
https://psnet.ahrq.gov/issue/missed…
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psnet.ahrq.gov/node/43956/psn-pdf
January 01, 2016 - Monitoring the harm associated with use of
anticoagulants in pediatric populations through trigger-
based automated adverse-event detection.
June 21, 2015
Patregnani JT, Spaeder MC, Lemon V, et al. Monitoring the harm associated with use of anticoagulants in
pediatric populations through trigger-based automated ad…
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psnet.ahrq.gov/node/42969/psn-pdf
October 31, 2014 - Reducing the burden of surgical harm: a systematic
review of the interventions used to reduce adverse events
in surgery.
October 31, 2014
Howell A-M, Panesar S, Burns EM, et al. Reducing the burden of surgical harm: a systematic review of the
interventions used to reduce adverse events in surgery. Ann Surg. 2014;2…
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psnet.ahrq.gov/node/46843/psn-pdf
June 21, 2018 - Electronic health record reviews to measure diagnostic
uncertainty in primary care.
June 21, 2018
Bhise V, Rajan SS, Sittig DF, et al. Electronic health record reviews to measure diagnostic uncertainty in
primary care. J Eval Clin Pract. 2018;24(3):545-551. doi:10.1111/jep.12912.
https://psnet.ahrq.gov/issue/elect…
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psnet.ahrq.gov/node/41967/psn-pdf
May 10, 2013 - A comparative review of patient safety initiatives for
national health information technology.
May 10, 2013
Magrabi F, Aarts J, Nohr C, et al. A comparative review of patient safety initiatives for national health
information technology. Int J Med Inform. 2013;82(5):e139-48. doi:10.1016/j.ijmedinf.2012.11.014.
htt…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-b.docx
June 02, 2025 - Strategy 2: Communicating to Improve Quality (Tool 3)
Long-Term Care Safety Toolkit
AHRQ Safety Program for Ambulatory Surgery
Implementation Guide
Appendix B. Your First Checklist Meeting Guide
The following document is a sample agenda and topics you should consider discussing when your implementation team meets fo…
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psnet.ahrq.gov/node/45901/psn-pdf
April 12, 2017 - Development and applications of the Veterans Health
Administration's Stratification Tool for Opioid Risk
Mitigation (STORM) to improve opioid safety and prevent
overdose and suicide.
April 12, 2017
Oliva EM, Bowe T, Tavakoli S, et al. Development and applications of the Veterans Health Administration's
Stratifica…
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psnet.ahrq.gov/node/42298/psn-pdf
December 31, 2014 - Using statistical text classification to identify health
information technology incidents.
December 31, 2014
Chai KEK, Anthony S, Coiera E, et al. Using statistical text classification to identify health information
technology incidents. J Am Med Inform Assoc. 2013;20(5):980-5. doi:10.1136/amiajnl-2012-001409.
htt…
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psnet.ahrq.gov/issue/core-elements-hospital-diagnostic-excellence-dxex
April 26, 2023 - Multi-use Website
Core Elements of Hospital Diagnostic Excellence (DxEx).
Citation Text:
Core Elements of Hospital Diagnostic Excellence (DxEx). Centers for Disease Control and Prevention.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
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psnet.ahrq.gov/node/47875/psn-pdf
July 19, 2019 - Observer-based tools for non-technical skills assessment
in simulated and real clinical environments in healthcare:
a systematic review.
July 19, 2019
Higham H, Greig PR, Rutherford J, et al. Observer-based tools for non-technical skills assessment in
simulated and real clinical environments in healthcare: a syste…
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psnet.ahrq.gov/node/43653/psn-pdf
January 01, 2015 - Evaluating inpatient mortality: a new electronic review
process that gathers information from front-line
providers.
December 19, 2014
Provenzano A, Rohan S, Trevejo E, et al. Evaluating inpatient mortality: a new electronic review process
that gathers information from front-line providers. BMJ Qual Saf. 2015;24(1)…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_2_Nurse_Chklst_508.docx
June 02, 2025 - Strategy 3: Bedside Shift Report (Tool 2)
Strategy 1: Working with Patients & Families as Advisors
[Type text] [Type text] [Type text]
Strategy 3: Nurse Bedside Shift Report (Tool 2)
Bedside Shift Report Checklist
Introduce the nursing staff to the patient and family. Invite the patient and family to take part in th…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/aa2HjKg6Gz6gm4mRPDLxhc
Clinical Summary: Interventions to Prevent Falls in Community-Dwelling Older Adults
Clinical Summary: Interventions to Prevent Falls in Community-Dwelling Older Adults
Population Community-dwelling adults 65 years or older at increased risk for falls , w ithout osteoporosis or vitamin D deficiency
Recomme…
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www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual/procedure-manual-appendix-xi-tool-assess-adequacy-and-certainty-evidence-task-force-recommendation
July 01, 2017 - Procedure Manual Appendix XI. Tool to Assess Adequacy and Certainty of Evidence for a Task Force Recommendation
Share to Facebook
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Print
Population or Group 1
Population or Group 2
…
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psnet.ahrq.gov/node/45167/psn-pdf
May 25, 2016 - AHRQ Communication and Optimal Resolution (CANDOR)
Toolkit.
May 25, 2016
Rockville, MD: Agency for Healthcare Research and Quality; May 2016.
https://psnet.ahrq.gov/issue/ahrq-communication-and-optimal-resolution-candor-toolkit
Traditionally, health systems have disclosed adverse events to patients only through a …
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/learning_pt_narratives_053123-ginsberg.pdf
June 02, 2025 - Learning from Patient Narratives Through Innovative Feedback Reporting Methods Webcast - Welcome from AHRQ
Welcome from AHRQ
Caren Ginsberg, PhD
Director, CAHPS & SOPS Programs, AHRQ
AHRQ’s Core Competencies
• AHRQ is a research and development agency in the U.S.
Department of Health and Human Services
► Healt…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/U3AGfV3Md5etC6ka97xtZR
Screening for Skin Cancer
Figure. Screening for Preeclampsia: Clinical Summary
Population Pregnant women without a known diagnosis of preeclampsia or hypertension
Recommendation
Screen for preeclampsia with blood pressure measurements throughout pregnancy.
Grade: B
Risk Assessment
All pregna…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/gUMryjH8YC47MFRqfnmmD3
Screening for High Blood Pressure in Adults: Clinical Summary
Screening for High Blood Pressure in Adults: Clinical Summary
Population Adults aged ≥18 y without known hypertension
Recommendation
Screen for high blood pressure; obtain measurements outside of the clinical setting for diagnostic confirmat…