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  1. Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee. | PSNet

    psnet.ahrq.gov/issue/healthcare-inspection-emergency-department-patient-deaths-memphis-vamc-memphis-tennessee
    November 29, 2023 - Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. … Share Facebook Twitter Linkedin Copy URL November 13, 2013 Washington … , DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. … Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. … DC VA Medical Center.

  2. Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus. | PSNet

    psnet.ahrq.gov/issue/electronic-health-record-modernization-caused-pharmacy-related-patient-safety-issues
    January 31, 2024 - Washington, DC: The Veterans Affairs Inspector General; March 21, 2024. … Share Facebook Twitter Linkedin Copy URL April 10, 2024 Washington … , DC: The Veterans Affairs Inspector General; March 21, 2024. … Washington, DC: The Veterans Affairs Inspector General; March 21, 2024. … November 13, 2013 Critical Deficiencies at the Washington DC VA Medical Center.

  3. Department of Health and Human Services Program Support Center (PSC) | Digital Healthcare Research

    digital.ahrq.gov/funding-mechanism/department-health-and-human-services-program-support-center-psc
    January 01, 2023 - Citation Radley DC, Wasserman MR, Olsho LEW, et al. … Washington, DC: The National Academies Press, 2011. … Washington, DC: The National Academies Press, 2011. … Washington, DC: The National Academies Press.

  4. Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA. | PSNet

    psnet.ahrq.gov/issue/deficiencies-after-new-electronic-health-record-go-live-mann-grandstaff-va-medical-center
    March 16, 2022 - Washington, DC: VA Office of Inspector General; March 17, 2022. … Share Facebook Twitter Linkedin Copy URL March 30, 2022 Washington … , DC: VA Office of Inspector General ; March 17, 2022. … Washington, DC: VA Office of Inspector General; March 17, 2022. … April 26, 2006 Critical Deficiencies at the Washington DC VA Medical Center.

  5. Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana. | PSNet

    psnet.ahrq.gov/issue/deficiencies-emergent-and-outpatient-care-patient-alcohol-use-disorder-richard-l-roudebush-va
    July 13, 2022 - Washington, DC: VA Office of the Inspector General; March 29, 2023. Report no. 21-03680-80. … Share Facebook Twitter Linkedin Copy URL April 19, 2023 Washington … , DC: VA Office of the Inspector General; March 29, 2023. … Washington, DC: VA Office of the Inspector General; March 29, 2023. Report no. 21-03680-80. … DC VA Medical Center.

  6. Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. | PSNet

    psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system
    April 19, 2023 - Washington, DC: Department of Veterans Affairs, Office of Inspector General.  July 29, 2021. … Share Facebook Twitter Linkedin Copy URL August 25, 2021 Washington … , DC: Department of Veterans Affairs, Office of Inspector General.  … Washington, DC: Department of Veterans Affairs, Office of Inspector General.  July 29, 2021. … DC VA Medical Center.

  7. Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee. | PSNet

    psnet.ahrq.gov/issue/deficiencies-care-care-coordination-and-facility-response-patient-who-died-suicide-memphis-va
    December 16, 2020 - Washington, DC: Department of Veterans Affairs, Office of Inspector General; September 3, 2020. … Share Facebook Twitter Linkedin Copy URL September 30, 2020 Washington … , DC: Department of Veterans Affairs, Office of Inspector General; September 3, 2020. … Washington, DC: Department of Veterans Affairs, Office of Inspector General; September 3, 2020. … DC VA Medical Center.

  8. When There's Harm in the Hospital: Can Transparency Replace "Deny and Defend"? | PSNet

    psnet.ahrq.gov/issue/when-theres-harm-hospital-can-transparency-replace-deny-and-defend
    April 02, 2014 - Washington, DC: George Washington University. March 11, 2016. … Washington, DC: George Washington University. March 11, 2016. … Washington, DC: George Washington University. March 11, 2016.

  9. Care Concerns and Deficiencies in Facility Leaders’ and Staff’s Responses Following a Medical Emergency at the Carl T. Hayden VA Medical Center in Phoenix, Arizona. | PSNet

    psnet.ahrq.gov/issue/care-concerns-and-deficiencies-facility-leaders-and-staffs-responses-following-medical
    January 16, 2025 - Washington DC: Veterans Affairs Office of Inspector General; July 2024. … Share Facebook Twitter Linkedin Copy URL September 18, 2024 Washington … DC : Veterans Affairs Office of Inspector General ; July 2024. … Washington DC: Veterans Affairs Office of Inspector General; July 2024.

  10. Department of Defense Health Care Quality. | PSNet

    psnet.ahrq.gov/issue/department-defense-health-care-quality
    February 11, 2025 - Washington DC: Office of the Assistant Secretary of Defense; Tricare Management Activity: 2011. … Share Facebook Twitter Linkedin Copy URL January 10, 2007 Washington … DC: Office of the Assistant Secretary of Defense; Tricare Management Activity: 2011. … Washington DC: Office of the Assistant Secretary of Defense; Tricare Management Activity: 2011.

  11. Announcing 2009 Leapfrog top hospitals. | PSNet

    psnet.ahrq.gov/issue/announcing-2009-leapfrog-top-hospitals
    June 21, 2023 - Washington, DC: Leapfrog Group; December 4, 2009. … Share Facebook Twitter Linkedin Copy URL December 16, 2009 Washington … , DC: Leapfrog Group; December 4, 2009. … Washington, DC: Leapfrog Group; December 4, 2009.

  12. ARRA Delivery System Initiative | Agency for Healthcare Research and Quality

    www.ahrq.gov/practiceimprovement/delivery-initiative/arragrantee-williams.html
    December 01, 2017 - Washington, DC; October 13, 2011. Robinson J. … Washington DC; November 29, 2011. … Washington, DC; June 12, 2012. Robinson JC, MacPherson K. … Washington, DC; February 7, 2013. http://www.youtube.com/watch?

  13. Ten Years After Keeping Patients Safe: Have Nurses' Work Environments Been Transformed? | PSNet

    psnet.ahrq.gov/issue/ten-years-after-keeping-patients-safe-have-nurses-work-environments-been-transformed
    April 04, 2018 - Washington, DC: George Washington University School of Nursing. March 14, 2014;22:1-8. … Washington, DC: George Washington University School of Nursing. March 14, 2014;22:1-8. … Washington, DC: George Washington University School of Nursing. March 14, 2014;22:1-8.

  14. References | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-6.html
    June 01, 2021 - Washington, DC: National Academies Press; 2015. https://www.ncbi.nlm.nih.gov/books/NBK338596/ . … Washington, DC: National Academies Press; 1999. https://www.ncbi.nlm.nih.gov/books/NBK225182/ . … Washington, DC: National Academies Press; 2001. https://www.ncbi.nlm.nih.gov/books/NBK222274/ . … Washington, DC: National Academies Press; 2013. https://www.ncbi.nlm.nih.gov/books/NBK207225/ . … Washington, DC: National Academy of Medicine; 2012. https://doi.org/10.31478/201206a .

  15. Safer Together Annual Report. | PSNet

    psnet.ahrq.gov/issue/perfecting-detection-understanding-source-harm
    May 27, 2020 - Washington, DC: Children's Hospital Association. … Washington, DC: Children's Hospital Association. … Washington, DC: Children's Hospital Association.

  16. Diagnostic Safety Toolkit. | PSNet

    psnet.ahrq.gov/issue/diagnostic-safety-toolkit
    December 05, 2024 - Washington DC: Children's Hospital Association. May 2020. … Washington DC: Children's Hospital Association . May 2020 . … Washington DC: Children's Hospital Association. May 2020.

  17. References | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/ref.html
    June 01, 2010 - Washington, DC: National Academies Press; 2001. 2. Katz S, Ford AB, Moskowitz RW, et al. … Washington, DC: National Academies Press; 2006. 11. Teaster PB, Otto JM, Dugar TA, et al. … Washington, DC: General Accounting Office; June 20, 2003. … Washington, DC: The National Academies Press; 2003. 21. McGlynn EA.

  18. Guidelines for Integrating Electronic Patient-Reported Outcomes Into Health Systems - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/r01hs023785-lavallee-final-report-2021.pdf
    January 01, 2021 - Poster at: American Medical Informatics Association Annual Symposium; 2019 Nov 16-21, Washington, DC. … Poster at: Academy Health Annual Research Meeting; 2019 Jun 1-3, Washington DC. 8. … Workshop at: American Medical Informatics Association Annual Symposium; 2019 Nov 16-21, Washington, DC … Presentation at: Workshop on Interactive Systems in Health Care; 2017 Nov 3, Washington, DC. 9. … Washington, DC: The National Academies Press; 2007. 21. Chung AE, Basch EM.

  19. Diagnostic Safety and Quality Webinar Series: Overview and Implications for Hospitals. | PSNet

    psnet.ahrq.gov/issue/diagnostic-safety-and-quality-webinar-series-overview-and-implications-hospitals
    June 21, 2023 - Washington DC: The Leapfrog Group; 2023. … Share Facebook Twitter Linkedin Copy URL November 3, 2023 Washington … DC: The Leapfrog Group; 2023. … Washington DC: The Leapfrog Group; 2023.

  20. Quality Improvement and Patient Safety Competencies Across the Learning Continuum. | PSNet

    psnet.ahrq.gov/issue/quality-improvement-and-patient-safety-competencies-across-learning-continuum
    November 06, 2019 - Washington, DC: Association of American Medical Colleges; 2019. ISBN: 9781577541882. … Washington, DC: Association of American Medical Colleges; 2019. ISBN: 9781577541882. … Washington, DC: Association of American Medical Colleges; 2019. ISBN: 9781577541882.
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