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psnet.ahrq.gov/node/851925/psn-pdf
August 02, 2023 - Deficiencies in Emergency Department Care for a Patient
Who Died by Suicide at the John Cochran Division of the
VA St. Louis Health Care System in Missouri.
August 2, 2023
Washington DC: Department of Veterans Affairs, Office of Inspector General; June 29, 2023. Report no.
22-01540-146.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/60244/psn-pdf
April 22, 2020 - Perioperative COVID-19 defense: an evidence-based
approach for optimization of infection control and
operating room management.
April 22, 2020
Dexter F, Parra MC, Brown JR, et al. Perioperative COVID-19 defense: an evidence-based approach for
optimization of infection control and operating room management. Anesth …
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psnet.ahrq.gov/node/74144/psn-pdf
December 01, 2021 - Her husband died by suicide. She sued his pain
doctors—a rare challenge over an opioid dose reduction.
December 1, 2021
Joseph A. STAT. November 22, 2021
https://psnet.ahrq.gov/issue/her-husband-died-suicide-she-sued-his-pain-doctors-rare-challenge-over-
opioid-dose-reduction
The opioid epidemic has put regulator…
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psnet.ahrq.gov/node/46255/psn-pdf
September 06, 2017 - Patient Safety in the Home: Assessment of Issues,
Challenges, and Opportunities.
September 6, 2017
Carpenter D, Famolaro T, Hassell S, et al. Cambridge, MA: Institute for Healthcare Improvement; 2017.
https://psnet.ahrq.gov/issue/patient-safety-home-assessment-issues-challenges-and-opportunities
The ambulatory env…
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psnet.ahrq.gov/node/47725/psn-pdf
March 06, 2019 - Overcoming human barriers to safety event reporting in
radiology.
March 6, 2019
Siewert B, Brook OR, Swedeen S, et al. Overcoming Human Barriers to Safety Event Reporting in
Radiology. Radiographics. 2019;39(1):251-263. doi:10.1148/rg.2019180135.
https://psnet.ahrq.gov/issue/overcoming-human-barriers-safety-event-…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/team-info-form.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Background Quality Improvement Team Information Form
AHRQ Safety Program for Perinatal Care
Background Quality Improvement Team Information Form
Who should use this tool? Health care teams
Please indicate staff members designated as Labor and Delivery Quality Improvement Team…
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psnet.ahrq.gov/node/45836/psn-pdf
July 02, 2017 - Improving patient safety: avoiding unread imaging exams
in the National VA enterprise electronic health record.
July 2, 2017
Bastawrous S, Carney B. Improving Patient Safety: Avoiding Unread Imaging Exams in the National VA
Enterprise Electronic Health Record. J Digit Imaging. 2017;30(3):309-313. doi:10.1007/s10278…
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psnet.ahrq.gov/node/41045/psn-pdf
July 02, 2014 - Relating faults in diagnostic reasoning with diagnostic
errors and patient harm.
July 2, 2014
Zwaan L, Thijs A, Wagner C, et al. Relating faults in diagnostic reasoning with diagnostic errors and patient
harm. Acad Med. 2012;87(2):149-156. doi:10.1097/ACM.0b013e31823f71e6.
https://psnet.ahrq.gov/issue/relating-fau…
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psnet.ahrq.gov/node/46960/psn-pdf
July 18, 2018 - What every graduating resident needs to know about
quality improvement and patient safety: a content
analysis of 26 sets of ACGME milestones.
July 18, 2018
Lane-Fall MB, Davis JJ, Clapp JT, et al. What Every Graduating Resident Needs to Know About Quality
Improvement and Patient Safety: A Content Analysis of 26 Se…
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psnet.ahrq.gov/node/45594/psn-pdf
December 19, 2017 - Teaching quality improvement and patient safety in
residency education: strategies for meaningful resident
quality and safety initiatives.
December 19, 2017
Morrison RJ, Bowe SN, Brenner MJ. Teaching Quality Improvement and Patient Safety in Residency
Education: Strategies for Meaningful Resident Quality and Safet…
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit1-19.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Exhibit 1.19. Major Factors that Inhibit Lean Success at LHC
Previous Page Next Page
Table of Contents
Improving Care Delivery Through Lean: Implementation Case Studies
Introduction to the Case Studies
Case 1. Lakeview Healthcare …
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psnet.ahrq.gov/node/45115/psn-pdf
September 07, 2016 - Despite federal legislation, shortages of drugs used in
acute care settings remain persistent and prolonged.
September 7, 2016
Chen SI, Fox ER, Hall K, et al. Despite Federal Legislation, Shortages Of Drugs Used In Acute Care
Settings Remain Persistent And Prolonged. Health Aff (Millwood). 2016;35(5):798-804.
doi:…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/identifying-delirium.pdf
June 01, 2021 - Identifying Delirium
IDENTIFYING DELIRIUM
ABCs OF IDENTIFICATION
Acute/subacute
• Altered mental status with
change in attention
Behavioral disturbance
• (Restless, agitated, combative)
Changes in consciousness
• (Jittery, drowsy, difficult to
arouse)
COMMON CAUSES OF DELIRIUM
COMMON…
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psnet.ahrq.gov/node/48089/psn-pdf
June 19, 2019 - Physician impairment and rehabilitation: reintegration
into medical practice while ensuring patient safety: a
position paper from the American College of Physicians.
June 19, 2019
Candilis PJ, Kim DT, Sulmasy LS, et al. Physician Impairment and Rehabilitation: Reintegration Into
Medical Practice While Ensuring Pat…
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www.ahrq.gov/research/findings/final-reports/stpra/stpraexh3.html
April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Exhibit 3. Inclusion and exclusion criteria for literature review
Previous Page Next Page
Table of Contents
Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Executive Summary
Chap…
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psnet.ahrq.gov/node/35328/psn-pdf
May 19, 2015 - Applicability of Healthcare Failure Mode and Effects
Analysis to healthcare epidemiology: evaluation of the
sterilization and use of surgical instruments.
May 19, 2015
Weinstein RA, Linkin DR, Sausman C, et al. Applicability of Healthcare Failure Mode and Effects Analysis
to Healthcare Epidemiology: Evaluation of …
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psnet.ahrq.gov/node/73914/psn-pdf
October 06, 2021 - Is there a mismatch between the perspectives of patients
and regulators on healthcare quality? A survey study.
October 6, 2021
Bouwman R, Bomhoff M, Robben PB, et al. Is there a mismatch between the perspectives of patients and
regulators on healthcare quality? A survey study. J Patient Saf. 2021;17(7):473-482.
do…
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psnet.ahrq.gov/node/852276/psn-pdf
August 09, 2023 - Parent experiences with the process of sharing inpatient
safety concerns for children with medical complexity: a
qualitative analysis.
August 9, 2023
Kieren MQ, Kelly MM, Garcia MA, et al. Parent experiences with the process of sharing inpatient safety
concerns for children with medical complexity: a qualitative a…
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psnet.ahrq.gov/node/60271/psn-pdf
April 29, 2020 - Pain management best practices from multispecialty
organizations during the COVID-19 pandemic and public
health crises.
April 29, 2020
Cohen SP, Baber ZB, Buvanendran A, et al. Pain Management Best Practices from Multispecialty
Organizations During the COVID-19 Pandemic and Public Health Crises. Pain Med. 2020;21(…
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psnet.ahrq.gov/node/46429/psn-pdf
October 04, 2017 - Clinician perspectives on the management of abnormal
subcritical tests in an urban academic safety-net health
care system.
October 4, 2017
Clarity C, Sarkar U, Lee J, et al. Clinician Perspectives on the Management of Abnormal Subcritical Tests
in an Urban Academic Safety-Net Health Care System. Jt Comm J Qual Pat…