-
psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - Caution, Interrupted
September 1, 2004
Wears RL. Caution, Interrupted. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/caution-interrupted
The Case
A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and
neutropenia presented to the emergency department (ED) with …
-
psnet.ahrq.gov/node/33699/psn-pdf
August 01, 2010 - Operationalizing Patient Safety at Academic Medical
Centers
August 1, 2010
Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet
[internet]. 2010.
https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
Perspective
Academic medical…
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psnet.ahrq.gov/node/49739/psn-pdf
August 21, 2015 - Breathe Easy: Safe Tracheostomy Management
August 21, 2015
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
The Case
A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/110-ss-lfd-sample.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects Tool—Sample
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
What Is a Defect?
A defect is any clinical or operational event or situation that you would not want to happen again. This could include i…
-
effectivehealthcare.ahrq.gov/sites/default/files/infectiousdisease_hi_impact.pdf
December 01, 2013 - Experts noted that several societal barriers to acceptance of the procedure could prevent
diffusion … following intervention components:
participant education and activation, assessment of treatment barriers … be met with strong enthusiasm from
many patients and clinicians, experts thought; however, other barriers … One expert representing a health systems perspective stated that barriers to
physician acceptance would … Experts noted that several societal barriers to acceptance
of the procedure may prevent diffusion;
-
www.uspreventiveservicestaskforce.org/home/getfilebytoken/XW6XUe2wRmkM-6Rrbn_462
February 01, 2023 - Serological Screening for Genital Herpes: A Reaffirmation Evidence Update for the U.S. Preventive Services Task Force
Evidence Synthesis
Number 224
Serological Screening for Genital Herpes: A
Reaffirmation Evidence Update for the U.S. Preventive
Services Task Force
Prepared for:
Agency for Healthcare…
-
digital.ahrq.gov/sites/default/files/docs/citation/r21hs024553-bardach-final-report-2018.pdf
January 01, 2018 - remain virtually
unheard in most hospital quality improvement efforts.13,14 One of the substantial barriers
-
digital.ahrq.gov/sites/default/files/docs/data-visualization-qa-053017.pdf
May 30, 2017 - QUESTION:
Is there any work underway to standardize harm barriers?
-
psnet.ahrq.gov/web-mm/perils-contrast-media
March 01, 2007 - in conference calls; (iii) review of the literature; (iv) participation in focus groups to discuss barriers
-
www.ahrq.gov/sites/default/files/wysiwyg/lhs/lhs_case_studies_bsw.pdf
April 01, 2019 - innovation comes from morning staff huddles, in which care teams discuss process
problems or workflow barriers
-
digital.ahrq.gov/sites/default/files/docs/page/UHIN_BusinessCaseReport.pdf
November 01, 2005 - This may present both barriers and opportunities.
-
psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
November 01, 2023 - second case likely would have benefitted from securing his airway while he was awake, the cognitive barriers
-
psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - In the metaphorical cheese, hazards are prevented by barriers, but holes in the
cheese represent opportunities
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
March 12, 2008 - This study confirmed that, even with barriers in
place, there was still a potential for
inappropriate
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psnet.ahrq.gov/web-mm/transfer-or-not-transfer
November 23, 2016 - The better possibility is to reduce administrative barriers to transfer.
-
psnet.ahrq.gov/node/49516/psn-pdf
August 01, 2006 - List barriers to performance of comprehensive physical examinations.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/module3-assessment-change-readiness-gap-analysis.pptx
August 25, 2015 - addressing the concerns of staff who are resistant to change, the organization can better understand the barriers
-
psnet.ahrq.gov/node/843151/psn-pdf
February 01, 2023 - An etic view of LGBTQ healthcare: barriers to access
according to healthcare providers and researchers
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-about-cusp-facilitator-guide.pdf
May 01, 2017 - communication among care
team members,
• Shared mental models,
• Expanded knowledge of potential
hazards and barriers
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation.pptx
May 01, 2017 - Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies.