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digital.ahrq.gov/sites/default/files/docs/page/findings-and-lessons-from-enabling-patient-centered-care-through-health-it.pdf
January 01, 2013 - inter-
vention strategies to reduce threats to patient safety
in ambulatory care settings and during transitions … decisionmaking and patient-clinician communica-
tion, 2) integration of patient information across
transitions … On February 24, 2010, AHRQ hosted a national
Web conference on transitions in care featuring
Dr. … One of the areas of interest for
this initiative was integration of patient information
across transitions … Only two projects addressed
the use of health IT to support patient-centered care
during transitions
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017010-bailey-final-report-2011.pdf
January 01, 2011 - patients with sickle cell anemia, cystic fibrosis, and cancer in the ambulatory setting, and during
transitions … Medication Safety during Transitions in Care. … There is significant evidence that
transitions in care, particularly between outpatient and inpatient … even less about the
incidence of harm to children from medications in ambulatory settings and during transitions … (including the emergency department) that require emergency
care or hospital admission, and during transitions
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/john-r-et-al-2007
January 01, 2007 - John R et al. 2007 "Development and evaluation of a PDA-based decision support system for pediatric depression screening."
Reference
John R, Buschman P, Chaszar M, et al. Development and evaluation of a PDA-based decision support system for pediatric depression screening. Stud Health Technol Inform 20…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/fish-george-s-terrien-e
January 01, 2023 - Fish A, George S, Terrien E, et al. "Workflow concerns and workarounds of readers in an urban safety net teleretinal screening study."
Reference
Fish A, George S, Terrien E, et al. Workflow concerns and workarounds of readers in an urban safety net teleretinal screening study. AMIA Annu Symp Proc 20…
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psnet.ahrq.gov/issue/aorn-position-statement-criminalization-human-errors-perioperative-setting
May 01, 2022 - Organizational Policy/Guidelines
AORN Position Statement on Criminalization of Human Errors in the Perioperative Setting.
Citation Text:
AORN Position Statement on Criminalization of Human Errors in the Perioperative Setting. AORN J. 2018;108(1):64-65. doi:10.1002/aorn.12292.
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psnet.ahrq.gov/issue/how-create-my-medicines-list
December 24, 2008 - Tools/Toolkit
How To Create a My Medicines List.
Citation Text:
How To Create a My Medicines List. Rockville, MD: Agency for Healthcare Research and Quality; October 2022.
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Save to your library
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www.ahrq.gov/news/newsroom/case-studies/201536.html
January 01, 2016 - University of Texas Southwestern Uses AHRQ’s TeamSTEPPS® Training to Improve Rapid Response Performance
Search All Impact Case Studies
January 2016
The performance of the University of Texas Southwestern Medical Center's (UTSW) rapid response team improved an average of 32 percent across five categories aft…
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psnet.ahrq.gov/issue/acog-committee-opinion-464-patient-safety-surgical-environment
July 18, 2019 - Commentary
ACOG Committee Opinion #464: patient safety in the surgical environment.
Citation Text:
Committee Opinion No. 464: Patient Safety in the Surgical Environment. Obstetrics & Gynecology. 2010;116(3). doi:10.1097/aog.0b013e3181f69b22.
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Format:
DOI Goog…
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psnet.ahrq.gov/node/47484/psn-pdf
March 20, 2019 - Bachelor's degree nurse graduates report better quality
and safety educational preparedness than associate
degree graduates.
March 20, 2019
Djukic M, Stimpfel AW, Kovner C. Bachelor's Degree Nurse Graduates Report Better Quality and Safety
Educational Preparedness than Associate Degree Graduates. Jt Comm J Qual Pa…
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digital.ahrq.gov/location/usa-oh-columbus
January 01, 2023 - USA, OH, Columbus
A Randomized Clinical Trial of Smartphone Virtual Reality for Pain Management During Burn Care Transition
Description
This research will adapt a pain management virtual reality application for use on a smartphone to manage pain during dressing changes in pedi…
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www.ahrq.gov/patient-safety/patients-families/engagingfamilies/guide.html
December 01, 2017 - Guide to Patient and Family Engagement in Hospital Quality and Safety
Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality. To promote stronger engagement, Agency for Healthcare Research and Quality developed the Guide to Patient and Fa…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-SOPS_101_Webcast-GINSBERG.pdf
September 01, 2020 - Understanding SOPS Surveys: A Primer for New Users (Webcast) - Ginsberg
Overview of AHRQ’s Patient Safety Priorities and Programs
Caren Ginsberg, Ph.D.
Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality (AHRQ)
6
AHRQ’s Core Competencies
AHRQ is a research and science-b…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/2-ginsberg-sops-hospital-survey-2-0-webcast.pdf
June 01, 2020 - AHRQ Webcast Introducing the New SOPS Hospital Survey 2.0 - Ginsberg
AHRQ’s Surveys on Patient Safety Culture™
(SOPS™) Program
Caren Ginsberg, PhD
Center for Quality Improvement and Patient Safety, AHRQ
6
AHRQ’s Core Competencies
AHRQ is a research and science-based agency of the U.S. Department of Health and …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-anemia.pdf
June 02, 2025 - NICU Family Information Packet, Appendix B, Anemia of Prematurity
Anemia Of Prematurity
Characteristics
■ Occurs during the normal developmental switch from fetal to adult hemoglobin synthesis.
■ Immediately after birth, the increase in blood oxygen content results in the downregulation of
erythropoietin.
■ On…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-vision.pdf
June 02, 2025 - NICU Family Information Packet, Appendix B, Vision Screening and Retinopathy
Vision Screening and Retinopathy of
Prematurity
Visual Deficits Seen in Preterm Infants
■ High-risk infants are more likely to have permanent visual deficits and/or show a delay in
visual development that persists until adolescence.
■ …
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www.ahrq.gov/patient-safety/reports/liability/acknowledgements.html
August 01, 2017 - Advances in Patient Safety and Medical Liability
Acknowledgments
Previous Page Next Page
Table of Contents
Advances in Patient Safety and Medical Liability
Preface
Acknowledgments
Prologue
Silence A Commentary
Reforming the Medical Liability System in Massachusetts: Communication, Apology,…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
April 04, 2008 - especially with respect to errors and opportunities for errors,
including errors that may occur in transitions … Thus, cycles of care can occur multiple times in one setting and/or involve transitions between
settings … facilitate understanding
of the processes of care in different interrelated parts of the system and transitions
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight12.pdf
January 01, 2020 - Illinois included new requirements for
perinatal care transitions in Medicaid
managed care contracts … have these processes in place and to
develop a performance improvement
plan that addresses care transitions … strengthening of the requirements in
Medicaid managed care contracts that
govern perinatal care transitions
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psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
September 01, 2017 - most of us who have been at that ground level think that there probably is underreporting—that those transitions … identified some areas where that was the case, but they particularly suggested that it's risky during these transitions … June 24, 2020
Applying requisite imagination to safeguard electronic health record transitions
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digital.ahrq.gov/sites/default/files/docs/citation/uc1hs015236-jose-final-report-2008.pdf
January 01, 2008 - At baseline, the areas most needing improvement were: non-punitive response to error,
handoffs and transitions … [A]
• From T0 to T1 ratings on handoffs & transitions declined significantly.