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2041. Preventing mistransfusions: an evaluation of institutional knowledge and a response. | PSNet
      psnet.ahrq.gov/issue/preventing-mistransfusions-evaluation-institutional-knowledge-and-response
      June 06, 2018 - Study Preventing mistransfusions: an evaluation of institutional knowledge and a response. Citation Text: MacDougall N, Dong F, Broussard L, et al. Preventing Mistransfusions: An Evaluation of Institutional Knowledge and a Response. Anesth Analg. 2018;126(1):247-251. doi:10.1213/ANE.0000…

2042. Strategies to reduce patient harm from infusion-associated medication errors: a scoping review. | PSNet
      psnet.ahrq.gov/issue/strategies-reduce-patient-harm-infusion-associated-medication-errors-scoping-review
      August 10, 2016 - Review Strategies to reduce patient harm from infusion-associated medication errors: a scoping review. Citation Text: Wolf ZR. Strategies to Reduce Patient Harm From Infusion-Associated Medication Errors: A Scoping Review. J Infus Nurs. 2018;36(1):58-65. doi:10.1097/NAN.0000000000000263.…

2043. Striving for a zero-error patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project. | PSNet
      psnet.ahrq.gov/issue/striving-zero-error-patient-surgical-journey-through-adoption-aviation-style-challenge-and
      July 10, 2017 - Study Striving for a zero-error patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project. Citation Text: Low DK, Reed MA, Geiduschek JM, et al. Striving for a zero-error patient surgical journey through adoption …

2044. Using HFMEA to assess potential for patient harm from tubing misconnections. | PSNet
      psnet.ahrq.gov/issue/using-hfmea-assess-potential-patient-harm-tubing-misconnections
      April 19, 2013 - Commentary Using HFMEA to assess potential for patient harm from tubing misconnections. Citation Text: Kimehi-Woods J, Shultz JP. Using HFMEA to assess potential for patient harm from tubing misconnections. Jt Comm J Qual Patient Saf. 2006;32(7):373-381. Copy Citation Format: …

2045. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45533/psn-pdf
      November 02, 2016 - Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach. November 2, 2016 Power M, Brewster L, Parry G, et al. Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach. BMJ Open. 2016;6(9):e011886. doi:10.1136/bmjopen-2016-…

2046. Review of alternatives to root cause analysis: developing a robust system for incident report analysis. | PSNet
      psnet.ahrq.gov/issue/review-alternatives-root-cause-analysis-developing-robust-system-incident-report-analysis
      November 14, 2018 - Review Review of alternatives to root cause analysis: developing a robust system for incident report analysis. Citation Text: Hagley G, Mills PD, Watts B, et al. Review of alternatives to root cause analysis: developing a robust system for incident report analysis. BMJ Open Qual. 2019;8(…

2047. About the Toolkit Development | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/about-toolkit.html
      May 01, 2017 - About the Toolkit Development Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care Facilities The toolkit was developed based on the experiences of approximately 500 nursing homes across the country that participated in the AHRQ Safety Program for Long-Term Care: HAIs/CAUTI, a 3-year implementation projec…

2048. Computer-Based Training Modules: Nasal Iodophor
      www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/training/cbt-iodophor.pptx
      March 01, 2022 - Computer-Based Training Modules: Nasal Iodophor Decolonization of Non-ICU Patients With Devices Section 11-8 Nursing Protocol Training Nasal Iodophor (10% Povidone-Iodine) AHRQ Pub. No. 20(22)-0036 March 2022 1 Targeted Decolonization Introduction Our hospital is adopting a targeted decolonization protocol for …

2049. Computer-Based Training Modules: Nasal Mupirocin
      www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/training/cbt-mupirocin.pptx
      March 01, 2022 - Computer-Based Training Modules: Nasal Mupirocin AHRQ Pub. No. 20(22)-0036 March 2022 Decolonization of Non-ICU Patients With Devices Section 11-7 Nursing Protocol Training Nasal Mupirocin 1 Targeted Decolonization Introduction Our hospital is adopting a targeted decolonization protocol for adult non-intensive …

2050. Daily Goals Checklist | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/daily-goals.html
      December 01, 2012 - Daily Goals Checklist CUSP Toolkit Effective communication is particularly important in the unit if complicated care plans are to be effectively managed by the care team Problem statement: Clear communication among health care providers is paramount. Communication failures lead to patient harm, increased l…

2051. Diagnostic errors in pediatric echocardiography: development of taxonomy and identification of risk factors. | PSNet
      psnet.ahrq.gov/issue/diagnostic-errors-pediatric-echocardiography-development-taxonomy-and-identification-risk
      April 12, 2019 - Study Diagnostic errors in pediatric echocardiography: development of taxonomy and identification of risk factors. Citation Text: Benavidez OJ, Gauvreau K, Jenkins KJ, et al. Diagnostic errors in pediatric echocardiography: development of taxonomy and identification of risk factors. Ci…

2052. Racial and ethnic disparities in patient safety. | PSNet
      psnet.ahrq.gov/issue/racial-and-ethnic-disparities-patient-safety
      March 03, 2011 - Review Racial and ethnic disparities in patient safety. Citation Text: Okoroh JS, Uribe EF, Weingart SN. Racial and Ethnic Disparities in Patient Safety. J Patient Saf. 2017;13(3):153-161. doi:10.1097/PTS.0000000000000133. Copy Citation Format: DOI Google Scholar PubMed Bib…

2053. Creating a just culture in the perioperative setting. | PSNet
      psnet.ahrq.gov/issue/creating-just-culture-perioperative-setting
      July 13, 2009 - Commentary Creating a just culture in the perioperative setting. Citation Text: Hooven K, Altmiller G. Creating a just culture in the perioperative setting. AORN J. 2024;119(2):152-160. doi:10.1002/aorn.14074. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML E…

2054. Severe hypertension in pregnancy: progress made and future directions for patient safety, quality improvement, and implementation of a patient safety bundle. | PSNet
      psnet.ahrq.gov/issue/severe-hypertension-pregnancy-progress-made-and-future-directions-patient-safety-quality
      October 23, 2024 - Commentary Severe hypertension in pregnancy: progress made and future directions for patient safety, quality improvement, and implementation of a patient safety bundle. Citation Text: Prior A, Taylor I, Gibson KS, et al. Severe hypertension in pregnancy: progress made and future directio…

2055. Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills. | PSNet
      psnet.ahrq.gov/issue/embracing-errors-simulation-based-training-effect-error-training-retention-and-transfer
      May 23, 2013 - Study Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills. Citation Text: Gardner AK, Abdelfattah K, Wiersch J, et al. Embracing Errors in Simulation-Based Training: The Effect of Error Training on Retent…

2056. A hybrid methodology for modeling risk of adverse events in complex health-care settings. | PSNet
      psnet.ahrq.gov/issue/hybrid-methodology-modeling-risk-adverse-events-complex-health-care-settings
      November 11, 2015 - Study A hybrid methodology for modeling risk of adverse events in complex health-care settings. Citation Text: Kazemi R, Mosleh A, Dierks M. A Hybrid Methodology for Modeling Risk of Adverse Events in Complex Health-Care Settings. Risk Anal. 2017;37(3):421-440. doi:10.1111/risa.12702. …

2057. Improving patient safety in intensive care units in Michigan. | PSNet
      psnet.ahrq.gov/issue/improving-patient-safety-intensive-care-units-michigan
      February 17, 2011 - Study Classic Improving patient safety in intensive care units in Michigan. Citation Text: Pronovost P, Berenholtz SM, Goeschel CA, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-212. doi:10.1016/j.jcrc.2007.09…

2058. The wisdom and justice of not paying for "preventable complications." | PSNet
      psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-preventable-complications
      January 22, 2014 - Commentary Classic The wisdom and justice of not paying for "preventable complications." Citation Text: Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.1…

2059. 037-Ss-Bed-Bathing-Chg-Cloths-Protocol (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/037-ss-bed-bathing-chg-cloths-protocol.docx
      April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Pre-Op Surgical Decolonization Protocol for Staff: Bathing With 2 Percent Chlorhexidine No-Rinse Cloths Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries The following protocol details the process for performing skin decol…

2060. | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/publications/search.html?page=13
      September 01, 2014 - Search Publications The Agency for Healthcare Research and Quality (AHRQ)'s publications offer practical information to help a variety of health care organizations, providers, and others make care safer in all health care settings. 131 - 140 of 191 Publications displayed Find Publications by Keyword or To…