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psnet.ahrq.gov/node/50600/psn-pdf
October 30, 2019 - HHS Guide for Clinicians on the Appropriate Dosage
Reduction or Discontinuation of Long-Term Opioid
Analgesics.
October 30, 2019
HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid
Analgesics. Washington DC: US Department of Health and Human Services. October 2019.
…
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psnet.ahrq.gov/node/60997/psn-pdf
October 07, 2020 - ‘You’re going to release him when he was hurting
himself?’
October 7, 2020
Dahlberg B. Kaiser Health News. September 29, 2020.
https://psnet.ahrq.gov/issue/youre-going-release-him-when-he-was-hurting-himself
This story discusses failures related emergency psychiatric assessment, including premature discharge,
imp…
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psnet.ahrq.gov/node/60531/psn-pdf
May 27, 2020 - Telenursing in incidents and disasters: a systematic
review of the literature.
May 27, 2020
Nejadshafiee M, Bahaadinbeigy K, Kazemi M, et al. Telenursing in incidents and disasters: a systematic
review of the literature. J Emerg Nurs. 2020. doi:10.1016/j.jen.2020.03.005.
https://psnet.ahrq.gov/issue/telenursing-in…
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psnet.ahrq.gov/node/45492/psn-pdf
September 28, 2016 - Understanding human over-reliance on technology.
September 28, 2016
ISMP Medication Safety Alert! Acute Care Edition. September 8, 2016;21:1-4.
https://psnet.ahrq.gov/issue/understanding-human-over-reliance-technology
Over-reliance on technology can contribute to error due to user complacency. Reviewing how the ten…
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psnet.ahrq.gov/node/44126/psn-pdf
May 13, 2015 - SAFER Electronic Health Records: Safety Assurance
Factors for EHR Resilience.
May 13, 2015
Sittig DF, Singh H, eds. Waretown, NJ: Apple Academic Press; 2015. ISBN: 9781771881173.
https://psnet.ahrq.gov/issue/safer-electronic-health-records-safety-assurance-factors-ehr-resilience
Implementation of electronic health…
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psnet.ahrq.gov/node/35235/psn-pdf
September 27, 2017 - What is the measure of a safe hospital? Medication errors
missed by risk management, clinical staff, and surveyors.
September 27, 2017
Grasso BC, Rothschild JM, Jordan CW, et al. What is the measure of a safe hospital? Medication errors
missed by risk management, clinical staff, and surveyors. J Psychiatr Pract. 20…
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psnet.ahrq.gov/node/47320/psn-pdf
September 05, 2018 - Patient safety climate: a study of Southern California
healthcare organizations.
September 5, 2018
Avramchuk AS, McGuire SJJ. Patient Safety Climate: A Study of Southern California Healthcare
Organizations. J Healthc Manag. 2018;63(3):175-192. doi:10.1097/JHM-D-16-00004.
https://psnet.ahrq.gov/issue/patient-safety…
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psnet.ahrq.gov/node/44983/psn-pdf
April 20, 2016 - Back to basics: counting soft surgical goods.
April 20, 2016
Spruce L. Back to Basics: Counting Soft Surgical Goods. AORN J. 2016;103(3):298-301; quiz 302-3.
doi:10.1016/j.aorn.2015.12.021.
https://psnet.ahrq.gov/issue/back-basics-counting-soft-surgical-goods
Despite heightened awareness of hazards associated with…
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psnet.ahrq.gov/node/41738/psn-pdf
June 10, 2018 - Inappropriate use of pharmacy bulk packages of IV
contrast media increases risk of infections.
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. September 20, 2012;17:1,3-4.
https://psnet.ahrq.gov/issue/inappropriate-use-pharmacy-bulk-packages-iv-contrast-media-increases-risk-
infections
This articl…
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psnet.ahrq.gov/node/36671/psn-pdf
January 18, 2011 - Increasing vigilance on the medical/surgical floor to
improve patient safety.
January 18, 2011
Jacobs JL, Apatov N, Glei M. Increasing vigilance on the medical/surgical floor to improve patient safety. J
Adv Nurs. 2007;57(5). doi:10.1111/j.1365-2648.2006.04161.x.
https://psnet.ahrq.gov/issue/increasing-vigilance-m…
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psnet.ahrq.gov/node/35043/psn-pdf
June 22, 2009 - Human factors engineering: a tool for medical device
evaluation in hospital procurement decision-making.
June 22, 2009
Ginsburg G. Human factors engineering: a tool for medical device evaluation in hospital procurement
decision-making. J Biomed Inform. 2005;38(3):213-9.
https://psnet.ahrq.gov/issue/human-factors-e…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/KdQef_VDT2kmHDX4ddNWmR
August 01, 2022 - Screening for Latent Tuberculosis Infection in Adults: US Preventive Services Task Force Recommendation Statement
Screening for Latent Tuberculosis Infection in Adults
US Preventive Services Task Force Recommendation Statement
US Preventive Services Task Force
Summary of Recommendation
See the Summary of Recommenda…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-research-report-unhealthy-alcohol-use-final.pdf
September 01, 2018 - Development of a Primary Care Guie for Implementing Evidence-Based Screening and Counseling for Unhealthy Alcohol Use With Epic-Based Electronic Health Record Tools: A Pilot Dissemination Project
Methods Research Report
Development of a Primary Care Guide for
Implementing Evidence-Based Screening and…
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integrationacademy.ahrq.gov/products/topic-briefs/telehealth
February 01, 2025 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
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Integrating Behavioral Health & Primary Care
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/mod2-facguide.html
March 01, 2017 - Module 2: Senior Leader Engagement: Facilitator Notes
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Slide 1: Module 2: Senior Leader Engagement
Say:
The Senior Leader Engagement module focuses on the role and responsibilities of the senior leader within the facility safety team. Engaging a senior l…
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www.ahrq.gov/sites/default/files/2024-04/etchegaray-report.pdf
January 01, 2024 - Final Progress Report: Safety Culture Research: Ways to improve existing methods
Safety Culture Research: Ways to improve existing methods (R13HS023062)
PI: Jason M. Etchegaray, PhD
Other Significant Contributor: Eric Thomas, MD, MPH
The University of Texas Health Science Center at Houston
04/05/2014-03/31/2015
J…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/lessons/lessons-performance-comparisons.pdf
October 01, 2019 - Lessons from the Field: Making Performance Comparisons
Lessons from the Field: Making Performance
Comparisons
Prepared for the Agency for Healthcare Research and Quality by L&M
Policy Research, LLC with guidance from the Pediatric Quality Measure
Program (PQMP) Grantees
i
Table of Contents
List o…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-icu-051314.pptx
February 07, 2014 - Slide 1
Preventing CAUTI in Specialized Patient Populations: The ICU
1
Hannah Wunsch, MD, MSc
Herbert Irving Assistant Professor of Anesthesiology and Epidemiology
Columbia University
Eugene Chu, MD, FHM
Director of Hospital Medicine
Boulder Community Hospital
Associate Clinical Professor of Medicine
University of Co…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_training.pptx
December 01, 2017 - Presentation: Science of Improving Patient Safety and Identifying Defects
The Science of Improving Patient Safety
and Identifying Defects
AHRQ Safety Program for Surgery
Onboarding
AHRQ Pub No. 16(18)-0004-15-EF
December 2017
Science of
Improving Patient Safety ‹#›
AHRQ Safety Program for Surgery – …
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - SPOTLIGHT CASE
Falling Through the Crack (in the Bedrails)
Citation Text:
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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