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  1. Johnson K et al. 2006 "Case report: activity diagrams for integrating electronic prescribing tools into clinical workflow." | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/experience/johnson-k-et-al-2006
    January 01, 2006 - Workflows also varied for new prescriptions and renewals.

  2. Estimating the hospital costs of inpatient harms. | PSNet

    psnet.ahrq.gov/issue/estimating-hospital-costs-inpatient-harms
    February 07, 2024 - Added cost varied from $32,000 for a surgical site infection to $9000 for a hospital-acquired urinary

  3. Hospital prescribing of opioids to Medicare beneficiaries. | PSNet

    psnet.ahrq.gov/issue/hospital-prescribing-opioids-medicare-beneficiaries
    December 04, 2016 - They found that new opioid use was common after discharge and that prescribing rates varied widely across

  4. Variation in emergency medical services workplace safety culture. | PSNet

    psnet.ahrq.gov/issue/variation-emergency-medical-services-workplace-safety-culture
    December 07, 2011 - This survey found that the perception of safety culture varied widely among prehospital emergency medical

  5. Investigating patient safety culture across a health system: multilevel modelling of differences associated with service types and staff demographics. | PSNet

    psnet.ahrq.gov/issue/investigating-patient-safety-culture-across-health-system-multilevel-modelling-differences
    November 12, 2014 - Perceptions of safety culture in an Australian health district varied between clinicians providing

  6. Safety culture in healthcare: a review of concepts, dimensions, measures and progress. | PSNet

    psnet.ahrq.gov/issue/safety-culture-healthcare-review-concepts-dimensions-measures-and-progress
    November 21, 2014 - This narrative review discusses the varied published definitions of safety culture and suggests that

  7. Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms. | PSNet

    psnet.ahrq.gov/issue/incidence-and-or-team-awareness-near-miss-and-retained-surgical-sharps-national-survey-united
    December 02, 2020 - members reported experiencing at least one RSS or NMS in the past year, responses to other survey items varied

  8. Algorithm based smartphone apps to assess risk of skin cancer in adults: systematic review of diagnostic accuracy studies. | PSNet

    psnet.ahrq.gov/issue/algorithm-based-smartphone-apps-assess-risk-skin-cancer-adults-systematic-review-diagnostic
    July 29, 2020 - included nine studies evaluating six different smartphone apps; reported sensitivity and specificity varied

  9. Conclusion and Future Directions | Agency for Healthcare Research and Quality

    www.ahrq.gov/data/apcd/backgroundrpt/conclusion.html
    April 01, 2017 - Varied measures in high-priority clinical areas theoretically feasible using APCD data.

  10. Engaging-Caregivers-Appendix-B (xls file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/engaging-caregivers-appendix-b.xlsx
    May 29, 2025 - caregivers and provide service delivery methods that offer more convenience and less burden Duration: Varied … Duration: Varied Followup: At discharge NR Satisfaction; Referrals to post-ICU recovery clinic A vs. … Duration: Varied depending on needs of patients/family caregivers Followup: 2 to 4 weeks post-discharge … Duration: NR (likely varied depending on LOS) Followup: 6 to 8 weeks NR Caregiver anxiety; Caregiver

  11. Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study. | PSNet

    psnet.ahrq.gov/issue/analysis-nature-and-contributory-factors-medication-safety-incidents-following-hospital
    October 25, 2023 - Overall, most incidents occurred at the prescribing stage, but varied by patient age group.

  12. Relationships between medications used in a mental health hospital and types of medication errors: a cross-sectional study over an 8-year period. | PSNet

    psnet.ahrq.gov/issue/relationships-between-medications-used-mental-health-hospital-and-types-medication-errors
    November 29, 2023 - The type of error varied widely across medication types (e.g., high-alert, psychotropic).

  13. Risk managers' descriptions of programs to support second victims after adverse events. | PSNet

    psnet.ahrq.gov/issue/risk-managers-descriptions-programs-support-second-victims-after-adverse-events
    May 11, 2016 - Approximately three-quarters of organizations reported having a support program , but they varied widely

  14. Differential impact of a crew resource management program according to professional specialty. | PSNet

    psnet.ahrq.gov/issue/differential-impact-crew-resource-management-program-according-professional-specialty
    July 31, 2013 - The results of a teamwork training program for operating room staff varied across professional specialty

  15. Specialist physicians' attitudes and practice patterns regarding disclosure of pre-referral medical errors. | PSNet

    psnet.ahrq.gov/issue/specialist-physicians-attitudes-and-practice-patterns-regarding-disclosure-pre-referral
    November 02, 2018 - Most believed that error disclosure did not benefit patients and disclosure practices varied significantly

  16. Board quality scorecards: measuring improvement. | PSNet

    psnet.ahrq.gov/issue/board-quality-scorecards-measuring-improvement
    June 16, 2011 - quality improvement efforts, but this study found that safety data scorecards used by hospital leadership varied

  17. Patient safety climate in hospitals: act locally on variation across units. | PSNet

    psnet.ahrq.gov/issue/patient-safety-climate-hospitals-act-locally-variation-across-units
    August 27, 2012 - Confirming a phenomenon noted in prior research , this study revealed that perception of safety culture varied

  18. Relationship between patient complaints and surgical complications. | PSNet

    psnet.ahrq.gov/issue/relationship-between-patient-complaints-and-surgical-complications
    January 05, 2011 - suggest a correlation, the absolute number of patient complaints was low and nature of patient complaints varied

  19. The impact of electronic medical records data sources on an adverse drug event quality measure. | PSNet

    psnet.ahrq.gov/issue/impact-electronic-medical-records-data-sources-adverse-drug-event-quality-measure
    July 31, 2013 - This study found that the rate of a trigger tool–based drug safety quality measure varied widely depending

  20. Risk mitigation in large scale systems: lessons from high reliability organizations. | PSNet

    psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations
    January 30, 2019 - Specifically, the authors stress the need to maintain effective and varied communication within a system
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