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  1. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
    June 01, 2025 - Comparison Tables for Making Healthcare Safer Reports The tables below compare all editions of the Agency for Healthcare Research and Quality’s Making Health Care Safer report . The first edition , published in 2001, was developed following the 1999 publication of To Err is Human: Building a Safer Health Sys…

  2. Deprescribing as a Patient Safety Strategy | PSNet

    psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
    December 15, 2024 - Deprescribing as a Patient Safety Strategy Citation Text: Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX …

  3. Chapter 5. Implement the VTE Prevention Protocol | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide5.html
    October 01, 2022 - Preventing Hospital-Associated Venous Thromboembolism Chapter 5. Implement the VTE Prevention Protocol Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. Analyze Care De…

  4. Root Cause Analysis Gone Wrong | PSNet

    psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
    August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…

  5. White Paper: Standardized Library of Lumbar Spondylolisthesis Outcome Measures (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/white-paper-lumbar-spondylolisthesis.pdf
    March 01, 2021 - White Paper: Standardized Library of Lumbar Spondylolisthesis Outcome Measures Research White Paper Standardized Library of Lumbar Spondylolisthesis Outcome Measures Research White Paper Standardized Library of Lumbar Spondylolisthesis Outcome Measures Prepared for: …

  6. New Oral Anticoagulants | PSNet

    psnet.ahrq.gov/web-mm/new-oral-anticoagulants
    July 01, 2011 - SPOTLIGHT CASE New Oral Anticoagulants Citation Text: Fang MC. New Oral Anticoagulants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

  7. Communication Failure—Who's in Charge? | PSNet

    psnet.ahrq.gov/web-mm/communication-failure-whos-charge
    April 01, 2018 - Communication Failure—Who's in Charge? Citation Text: Fackler J, Schwartz JM. Communication Failure—Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndN…

  8. The Consequences of Miscommunication Regarding a Possible Artifact | PSNet

    psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
    May 11, 2019 - SPOTLIGHT CASE The Consequences of Miscommunication Regarding a Possible Artifact Citation Text: Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…

  9. The Inside of a Time Out | PSNet

    psnet.ahrq.gov/web-mm/inside-time-out
    March 01, 2004 - The Inside of a Time Out Citation Text: Feldman DL. The Inside of a Time Out. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …

  10. Code Status Confusion | PSNet

    psnet.ahrq.gov/web-mm/code-status-confusion
    September 01, 2006 - SPOTLIGHT CASE Code Status Confusion Citation Text: Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndN…

  11. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. | PSNet

    psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
    January 29, 2021 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. Citation Text: Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…

  12. Perils in Diagnosing a Stroke | PSNet

    psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
    August 15, 2017 - Perils in Diagnosing a Stroke Citation Text: Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

  13. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation | PSNet

    psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
    November 25, 2020 - Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation Citation Text: Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. …

  14. Misuse of Prescription Stimulants in Adults (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/misuse-prescription-protocol.pdf
    September 13, 2024 - Misuse of Prescription Stimulants in Adults Evidence-based Practice Center (EPC) Rapid Review Protocol Project Title: Misuse of Prescription Stimulants in Adults I. Background and Objectives for the Systematic Review The U.S. Food and Drug Administration (FDA) has commissioned a rapid review on the misuse of att…

  15. The Worst Headache | PSNet

    psnet.ahrq.gov/web-mm/worst-headache
    July 01, 2016 - The Worst Headache Citation Text: Edlow JA. The Worst Headache. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  16. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
    January 01, 2024 - Spotlight Spotlight A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis 1 Source and Credits This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Garth Utter, MD, MSc, FACS…

  17. A New Model of Tracheostomy Care: Closing the Research–Practice Gap (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Clair.pdf
    January 01, 2004 - A New Model of Tracheostomy Care: Closing the Research–Practice Gap 521 A New Model of Tracheostomy Care: Closing the Research–Practice Gap Joel St. Clair Abstract Performance improvements have brought about fundamental changes in the past year at Walter Reed Army Medical Center (WRAMC), where a concerted …

  18. I. Introduction | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/reports/hotline/intro1.html
    May 01, 2016 - Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events I. Introduction Previous Page Next Page Table of Contents Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events Pr…

  19. C (pdf file)

    hcup-us.ahrq.gov/reports/methods/2010_05.pdf
    January 01, 2010 - C HCUP Methods Series kbr33831 Contact Information: Healthcare Cost and Utilization Project (HCUP) Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD 20850 http://www.hcup-us.ahrq.gov For Technical Assistance with HCUP Products: Email: hcup@ahrq.gov or Phone: 1-86…

  20. Comparative Effectiveness of Strategies to De-escalate Aggressive Behavior in Psychiatric Patients in Acute Care Settings (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/aggression_executive.pdf
    October 01, 2016 - The protocols used had some overlap but differed in important ways.
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